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Correct Usage of Modifier 79 for Multiple Procedures

National Government Services Medical Review department has identified widespread problems with the use of modifier 79 for multiple procedures.

The global surgical package (GSP) was established by CMS to ensure that all components of surgery (including pre and postoperative services) were bundled into one payment.

Modifier 79 (Unrelated procedure or service by the same physician during the postoperative Period) was established to simplify billing for services provided to a patient during the post-operative period that were unrelated to the original surgical procedure. Prepayment edits were put into place to detect services that were unbundled from the GSP. However, by billing services with modifier 79, they are excluded from those prepayment edits.

The Office of the Inspector General (OIG) initiated an investigation after receiving allegations that a provider was billing for surgeries that were never performed. The investigation substantiated the allegations and revealed that the provider was billing surgeries every five to six days. To avoid detection, the provider billed the surgeries using the modifier 79. The provider’s abuse of the modifier 79 enabled him to defraud the Medicare Program of a significant amount of dollars.

As such, the Centers for Medicare & Medicaid Services (CMS) has expressed concern about the use of modifier 79, as indicated in Change Request (CR) 6334. The CMS has instructed contractors to strengthen program safeguards to prevent improper payment for modifier 79.

National Government Services Medical Review department performed data analysis on the utilization of Modifier 79. The data showed some aberrancy of its usage. For that reason, the Medical Review department may implement appropriate corrective action(s) (e.g., establish prepayment edit, develop pre and postpayment reviews) in the near future.

The modifier 79 should not be reported with the procedure if it’s related to the original procedure or if it’s a staged procedure during the postoperative period. If the service performed is related to the original procedure, it is considered part of the global period, and modifier 79 should not be applied. However, if the related procedure was unplanned following the initial procedure during the postoperative period, modifier 78 should be reported. If the procedure is staged or related to the initial procedure during the postoperative period, modifier 58 should be applied.

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Correct Usage of Modifier 79 for Multiple Procedures
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