Matching CPT code with an ICD 10 code, this would seem to be a very straightforward process but there are always variations/exceptions to everything. Sometimes, there are related services that the physician is performing, global periods to contend with, etc. Modifiers will clarify extenuating circumstances, which should allow for payment when they otherwise may not. That said, the improper use of modifiers can be the cause of claim denials just as not using a modifier can be. When using modifiers, make sure you clearly understand what the modifier entails.
In this, and the following blogs, we identify 10 of the most commonly misused modifiers to help you become more aware of the issues surrounding them. We’ll help you understand why they are problematic and how you can use them correctly.
Modifier 58 Staged or related procedure or service by the same physician during the postoperative period may be necessary to indicate the performance of a procedure during the postoperative period was:
- Planned prospectively at the time of the original procedure, or “staged;”
- “More extensive” than (that is, goes beyond) the original procedure; or
- Therapy following a diagnostic surgical procedure.
When reporting Modifier 58, the physician may need to indicate that the procedure or service was:
- Planned prospectively at the time of the original procedure, or staged.
- More extensive than the original planned procedure.
- For therapy following a diagnostic surgical procedure.
- Do not use this modifier to report the treatment of a problem that requires a return to the operating room.
The existence of CPT Modifier 58 does not negate the global fee concept; therefore, services that are included in CPT as multiple sessions or are otherwise defined as including multiple services or events may not be billed with this modifier.
Modifier 58 should not alter the amount charged or paid for subsequent unrelated or staged procedures that are performed during the postoperative period of a previous procedure. Modifier -78 may drive a reduction because it is for management of a complication resulting from the previous procedure.
A patient has a malignant melanoma removed from his shoulder and the physician takes a lymph node biopsy (38510, Biopsy or excision of lymph node[s]; open, deep cervical node(s)). Pathology determines that the lymph node has metastatic malignancy, so the physician schedules the patient to come back for a lymph node dissection, which you would document with a code in the 38500-38555 (Biopsy or excision of lymph node(s); …) range, appending modifier 58 to the procedure code.
A procedure that is more extensive than the original procedure: On May 1, the patient presents to the OR for the removal of a right breast lesion. On May 3, the pathology report returns and indicates the lesion is malignant. On May 9, within the global period of the initial surgery, the patient is returned to the OR for a modified radical breast mastectomy by the same surgeon. Appropriate coding is:
May 1: 19120-RT Excision of the cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions (90 global days). Modifier RT Right side indicates location. The diagnosis is 239.3 Neoplasms of unspecified nature; breast.
May 9: 19307-58-RT Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle with 174.1 Malignant neoplasm of the female breast; a central portion.
The diagnoses are different for each procedure. The subsequent diagnosis discovery on May 3 resulted in the need for a more extensive procedure.
- Appending the modifier to ASC facility fee claims
- Appending the modifier to a procedure with XXX global period on the MPFSDB
- Appending the modifier to services listed in CPT as multiple sessions, (i.e. 67208, Destruction of localized lesion of the retina, one or more sessions)
- Reporting the treatment of a complication from the original surgery
- Unrelated procedures during the postoperative period