“Here’s the scenario: patient has a chronic ulcer left foot that comes in for regular debridements/wound care. Two weeks ago he has a full thickness ulcer and osteomyelitis at the 2nd toe right foot and I performed a partial amputation of the toe in the office. He comes in for postop check five days later and everything is fine. At his 2nd postoperative visit, I notice a new punctate ulcer plantar 2nd toe with exposed bone and progressing osteomyelitis. I did a prep and debrided the bone at this visit (Yes, authorization was submitted for a more proximal amputation at a future appointment.) I also debrided the wound on his left foot. The question I have is with a multiple modifier order/rule for the debridedment of the ulcer left foot. I billed the visit out as follows:
CPT 11044-78,T6
CPT 11042-59,79,LT
Should the order of the modifiers with the CPT 11042 be -59,79 or -79,59 (or does this matter?) I have seen coding recommendations that say that the 1st modifier should be the “pricing” modifier and the 2nd modifier should be the “procedure” modifier but I am not sure of this.”
What a hot mess! So, a patient has been coming into see the physician on a regular basis for debridement/wound care of a chronic ulcer on the left foot. On one of these encounters, he presents with a full thickness ulcer and osteomyelitis of the 2nd toe on the right foot. A partial amputation of the right 2nd toe needed to be performed in the office on that day.
The appropriate CPT code to bill is 28825 (Amputation, toe; interphalangeal joint). This would be appended by the T6 modifier. It is important to note that since the amputation was performed “2 weeks ago,” the postoperative global period for CPT code 28825 was 90 days. As of January 1, 2021, the postoperative global period was reduced to 0 days. This would certainly have an effect on the coding and billing of the subsequent procedures that were performed.
At the 2nd postoperative visit, there was a “new punctate ulcer” on the plantar aspect of the right 2nd toe with exposed bone and evidence that the osteomyelitis was progressing. The necrotic bone was debrided at this encounter. In addition, that chronic left foot ulcer had necrotic subcutaneous tissue excisionally debrided out from within.
The coding scenario for the date of service would be:
CPT 11044 – 78
CPT 11042 – 59, 79
Issue #1: It is important to note that you are no longer reimbursed per ulcer, wound or lesion. The key phrase is now 20 SQUARE CENTIMETERS. This is PER DEPTH OF DEBRIDEMENT, PER BODY. Anatomical modifiers are no longer used. To demonstrate that different depths of debridement were used, the 59 modifier (or the “X” modifier subset: XS) is used.
Issue #2: Since a 90 day postoperative global period was created by the 2nd toe, right foot partial amputation, it was appropriate to append the 78 modifier to CPT code 11044. The 78 modifier is defined as: UNPLANNED RETURN TO THE OPERATING/PROCEDURE ROOM BY THE SAME PHYSICIAN FOLLOWING INITIAL PROCEDURE FOR A RELATED PROCEDURE DURING THE POSTOPERATIVE PERIOD. It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure.
Issue #3: Since different depths of debridement were performed on the patient on the same date of service (ie. 11044, 11042), It is appropriate to append the 59 modifier to CPT code 11042 to indicate a DISTINCT PROCEDURAL SERVICE.
Issue #4: Since the debridement of the chronic left foot ulcer was clearly not related to the debridement of the ulcer on the 2nd toe of the right foot, the 79 modifier also needed to be appended to CPT code 11042. The 79 modifier is defined as: UNRELATED PROCEDURE BY THE SAME PHYSICIAN DURING THE POST-OPERATIVE PERIOD. Use when performing an unrelated procedure or service during the post-operative period of another surgical procedure.
As far as the correct order to append modifiers to the CPT codes is concerned, I feel that the most important modifier to append first more often than not would be the anatomical modifier to let the health insurance carrier know exactly where the procedure is being performed. In an instance like this one, where anatomical modifiers are not required, the 59 modifier would be the superseding modifier to inform the carrier that the CPT code that it is appended to is a Distinct Procedural Service from the other procedures performed on the same date of service.
As an aside, if the same procedure set was performed after January 1, 2021, the coding scenario would be:
CPT 11044
CPT 11042 – 59
Remember, CPT code 28825 now has a postoperative global period of 0 days (as does CPT code 28820).
This is my opinion.
Michael G. Warshaw
DPM, CPC
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