Reporting procedures and services performed in the outpatient setting may create a challenge for coders when a return to the operating room for a related or unrelated procedure or service becomes necessary. There are different modifiers used for outpatient setting like 59, 76, 77, 58, 78, 79 etc. but each one of them has to be used very carefully. Now we have new modifiers XE, XP, XS and XU along with 59 modifier for providing more specific information about the procedure performed. However, few modifiers like 58, 78 and 79 has to be understood clearly since it can be confused other modifiers. Modifiers are little tricky to understand, if you know how to use them then you can easily answer any question on modifiers in Certified Professional coder exam. Let us first know the full description about modifier 58.
Modifier 58, Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
Read also: Coding rules for Modifier 22, 23, 24 and 25
When to Use 58 modifier
Modifier 58 is utilized to identify those situations when a procedure or service may be staged (planned). While a return to the operating room for a related procedure may be commonplace, a staged (planned) procedure or service may not be as routine. I will try to clarify the intent when to exactly use Modifier 58 with procedure codes. As per the CPT coding guidelines, Modifier 58 is assigned for any subsequent procedure, which is planned or has to be performed with the related original procedure. Following three key points should be remembered before appending modifier 58 to the procedure codes.
a. Planned or anticipated (staged)
b. More extensive than the original procedure
c. For therapy following a surgical procedure.
If any of these criteria is mentioned, we can use Modifier 59 with CPT codes. In addition, modifier 58 may be utilized if a diagnostic endoscopy results in the decision to perform an open procedure. In this situation both procedures may be reported with modifier 58 appended to the HCPCS/CPT code for the open procedure.
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When we should not use Modifier 58
I already told before we can get confused with other modifiers while using Modifier 58. Here is the best example for unplanned return of the patient for any related problem of the original procedure. Such cases occur only when patient get some complication from the original procedure. In such cases, we have to use Modifier 78, which is used for unplanned return to the operating room.
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Modifier 78 – Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
Never use Modifier 58 for surgery CPT codes like 67208 which state“1 or more sessions or 1 or more visits” in the code narrative. The procedure should be staged or planned, the used of modifier 58 is not based on the number of visits.
Do not use Modifier 58 or 78 when any diagnostic procedure is turned into an open procedure. In such case, we will code the most complex procedure that is open procedure CPT code. The diagnostic procedure will get included in it. As per NCCI guidelines, if any planned laparoscopic procedure fails and is converted to an open procedure, only the open procedure is separately reported.
Finally, use of Modifier 58 is only within the global period. If the patient does not visit within the global period of the original procedure, use of modifier 58 or 78 is not appropriate.
Examples for Modifier 58 and 78
A patient has Central Venous catheter(36560-36571) placed in Chest. The Catheter has after few days gets malfunctioned. The patient suddenly visits to his physician within global period or postoperative period because of the catheter complication. Now, the physician performs the replacement of the Central venous Catheter. Now, because of the unplanned return of the patient to the operating room during postoperative or global period, the replacement CPT code (36580-36590) will be appended with Modifier 78.
Now if a patient had a removal of a breast lesion (CPT 19120) followed in less than 90 days by the removal of the entire breast (CPT 19307). The second procedure is more extensive than the original procedure and the documentation supports for the planned or staged procedure. In such cases, we will bill CPT 19307 with 58 modifier for the second procedure.
Read also: When to use Modifier 57 in Procedure Coding
When to use Modifier 79
Modifier -79 is used to explain that a patient requires surgery for a condition totally unrelated to the condition for which the first operation was performed.
Modifier 79 – Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
For example, a patient had an appendectomy and two weeks later had a gallbladder episode that necessitated removal of the gallbladder. Modifier -79 would be placed on the cholecystectomy code, indicating that the subsequent procedure was unrelated to the first procedure.