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Payers to Scrutinize Payments for Modifier 79

February 24, 2009:

A recent Centers for Medicare and Medicaid Services (CMS) transmittal instructs contractors to more stringently enforce current policies aimed at preventing separate payment for procedures performed during the global surgery period. 

This action is in response to a report issued by the Office of the Inspector General (OIG) titled “Management Implication Report on the Misuses of the Modifier 79.” This modifier for an unrelated procedure or service by the same physician during the postoperative period, is  used when an unrelated procedure or service is performed during the postoperative period of another major service. For example, if a patient underwent fracture care of the ankle but is seen during the 90-day global period of that procedure for care of a dislocated acromioclavicular joint, modifier 79 would be appended to code 23530 to indicate it is unrelated to the ankle fracture care, thus overriding payment denial as part of the global surgery package (GSP).

The GSP guidelines ensure that all of the individual components of a surgical procedure (i.e., the pre-, intra- and postoperative services) are bundled into one payment. Modifier 79 allows providers to bill for services provided to a patient during the postoperative period that were unrelated to the original surgical procedure. CMS and most other payers use prepayment edits to detect services unbundled from the GSP; however, services billed with modifier 79 are excluded from those prepayment edits.

The OIG received information insinuating that a provider was billing for podiatry surgeries that were never performed. As part of the investigation, the OIG discovered that the provider billed  surgeries for his patients every five to six days. To avoid detection and denials, this provider almost always appended modifier 79 when billing for the additional services. The lack of an edit to identify overuse of modifier 79, as well as the lack of an edit that allows contractors to detect extraordinarily high numbers of surgical procedures, allowed the provider to avoid detection.  

Deborah C. Hall
Clinical/Technical Editor


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