Modifier 58: Appropriate Use
Basics of Modifier 58
Staged or Related Procedure or Service by the Same Physician During the Postoperative Period
The modifier 58 is defined by CPT as ‘staged or related procedure or service by the same physician during the postoperative period.’ Further, according to CMS.gov, modifier 58 indicates that the procedure was:
- Planned, either at the time of the first procedure or prospectively.
- More extensive than the first procedure.
- For therapy after a diagnostic surgical procedure.
There’s some ambiguity here, because nowhere in the CPT manual does CMS clarify whether the above conditions are separated by ‘or,’ or ‘and.’ However, it’s generally assumed that the conditions are ‘or’ cases. That is, anyone of them can by itself trigger the use of modifier 58. For billing purposes, CMS states that the next procedure in the series starts a new post-operative period. The key with modifier 58 is that it almost always covers a procedure the doctor knew about before the end of the related, first operation.
Medicare requires a return to the operating room (OR) to apply modifier 58, ‘unless the patient’s condition was so critical there would be insufficient time for transport.’ The Medicare Claims Processing Manual, chapter 12, section 40.1 B, defines an operating room ‘as a place of service specifically equipped and staffed for the sole purpose of performing procedures. This term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite.’
Some people think that the physician has to specifically state-planned stages in order for a procedure to qualify for the 58 modifier. This is not the case. The subsequent procedure can be within a stated plan of care, or it can be implied, executing a more extensive procedure because the original procedure did not achieve the desired outcome as planned.
- Report when a procedure or service during the postoperative period was:
- Planned prospectively or at the time of the original procedure
- More extensive than the original procedure
- For therapy following a diagnostic surgical procedure
- When performing a second or related procedure during the postoperative period
- Staged procedures do not apply to claims for an assistant at surgery or services of an Ambulatory Surgical Center
- Doesn’t apply to procedures with XXX global period
- Unrelated procedures during the postoperative period
- Reporting the treatment of a complication from original surgery that requires a return to the operating room or service not separately payable that does not require a return to the operating room
Examples of Modifier 58
A surgeon performs a procedure to debride a sacral ulcer. During the procedure, the surgeon knows she must perform a skin graft on the ulcer site at a later date. The skin graft will be billed with modifier 58. Because during the original procedure, the physician knew the graft procedure would take place.
A patient undergoes a left breast biopsy and the physician diagnoses breast cancer. One week later, the surgeon performs a modified radical left breast mastectomy. The biopsy was the primary procedure resulting in a more extensive procedure, so the left breast mastectomy code would need a 58 modifier.
A patient with diabetes and advanced circulatory problems had a gangrenous toe removed from her left foot. At the time of the surgery, the physician advised of the possibility of amputating the left foot due to her condition. Three weeks later, the physician performed an amputation of the left foot. Procedure code 28820 (Amputation of the toe) (90 global surgery period); Procedure code 28805 (Amputation thru the metatarsal) with modifier 58. Documentation must substantiate the use of modifier 58.
Modifiers © Copyright 2021 American Medical Association
Unfortunately, not all insurers will pay you accurately even if you code in compliance with CPT rules. Be sure to have your staff appeal any denied or bundled claims. A review of your documentation by the insurer may actually result in payment for your work. Still, confused about appropriately using modifier 58? Don’t worry E2E Medical Billing Services has an experienced coding team that uses exact modifiers to avoid denials. To know more about our medical billing services call us at 888-552-1290 or write to us at [email protected]