CMS Warns of Modifier 79 Use

By
In CMS
February 26, 2009
4 Comments
92 Views

The Centers for Medicare & Medicaid Services (CMS) are instructing contractors to look much more closely at claims for services billed with modifier 79 Unrelated procedure or service by the same physician during the post operative period.

CMS Transmittal 442, Change Request (CR) 6334, issued Feb. 13, is in response to a Management Implication Report on the Misuses of the Modifier 79 conducted by the Office of Inspector General (OIG). In the report, the OIG describes a provider’s ability to defraud the Medicare program of a significant amount of money between 1994 and 2000 by billing for podiatry surgeries for his patients every five to six days. Modifier 79 was used to avoid detection. It worked, but only for a while.

Modifier 79 is excluded from pre-payment edits, so it is easily overlooked. The OIG concluded from its investigation that this exclusion and the lack of an edit to detect an unusually high number of surgeries on a single Medicare beneficiary are to blame.

To avoid future denials or audits, coders should ensure sufficient documentation exists to support modifier 79 use. Do not file claims for separate payment for additional procedures with a global surgery fee period if they were furnished during a prior procedure’s postoperative period and billed without modifier 79. Use modifier 79 only when the visit is unrelated to the surgery.

4 Responses to “CMS Warns of Modifier 79 Use”

  1. molejniczak says:

    I was told by a level 3 Medicare customer service representative that 79 is not even an acceptable modifier in their database earlier this week. Thank you for this information to help me show that it is acceptable when used appropriately.

  2. GOBIN COPPA says:

    WHAT IS THE PATIENT HAD A SURGERY AND THEN A FEW WEEKS LATER HAS A INJURY/DICLOCATION OF THE SAME ANATOMIC PART A FEW WEEKS INTO THE GLOBAL PERIOD WHAT IS YOUR VIEW ON THIS?

  3. Aylen H says:

    When can you use modifier 79?

  4. Judy Flynn says:

    If a provider bills for a colonoscopy and an egd on the same day. Is it appropriate for him to bill with modifier 79?
    I believ that this would indicate the patient had been taken to the Recovery Room after one of the procedures and then had an emergency of some kind that required a return to the OR.
    If the provider does an egd and then a colonoscopy during the same operative session, then use of the modifier 51 could be appropriate.

Leave a Reply

Your email address will not be published. Required fields are marked *


*

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

Menu Title