I&D in the Office During the Global Period

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Question:  

Our surgeon saw a patient in the office for a routine post-op check during the global period of a thyroidectomy. During the visit, the surgeon notes that the patient has some neck fullness and performs an incision and drainage in the office. I have the correct CPT code, but I am wondering if I should use Modifier 58 or 79. I think the correct modifier is modifier 79 because he documents a new diagnosis “chylous effusion”. Do you recommend modifier 58 or 79?

Answer:

The reporting (or not) of this service performed in the office, during the global period will be payor dependent. If the payor is Medicare, or follows Medicare rules, the visit is not reportable as this a complication of the original surgery.

If the payor follows CPT rules, and the surgeon determines this is not “typical postoperative care” then traditionally no modifiers are appended. Modifier 79 is typically reserved for an ‘unrelated’ procedure/ service at a different location. The chyle leak is secondary to the surgical intervention—thus if there had not been surgery, there would not be a chyle leak. Survey your private payors to determine which modifier, if any, is required.