Anesthesia Coding Alert

Reader Question: Reason for OR Return Dictates Modifier Choice

- Published on Thu, Apr 12, 2012

Question: A patient returned to the operating room (OR) later the same day of surgery because of post-op bleeding after a small bowel resection with lysis of adhesions. The surgeon performed a splenectomy during the second session. The same anesthesiologist was present for both surgeries. What modifier and documentation should I include with the claim?

Texas Subscriber

Answer: Submit 00790 (Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified) and a diagnosis for the postoperative bleeding, such as 998.1x (Hemorrhage or hematoma or seroma complicating a procedure). Coders vary in their advice on whether to include a modifier for the procedure:

  • Modifier 59 (Distinct procedural service) identifies procedures that are not normally reported together but were performed on a different body site or during a different procedure or surgical session, required a separate incision, were related to separate injuries, or were performed during different sessions or encounters.
  • Modifier 78 [...]

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