How accurate you can use Modifier 58 in Medical Billing?

Blog-How-accurate-you-can-use-Modifier-58-in-Medical-BillingThe modifier 58 is defined by CPT as “staged or related procedure or service by the same physician during the post-operative period.” It may be necessary to indicate that the performance of a procedure or service during the postoperative period was a) planned or anticipated (staged); b) more extensive than the original procedure, or c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure.

Services may not be “unrelated” to the procedure code creating the postoperative global period and also “related” to another procedure code performed by the same physician during that same original surgical session.

A septoplasty (30520, 90-day global) and functional endoscopic sinus surgery (FESS, 0-day or 10-day global) are performed during the same surgical session. An endoscopic sinus debridement (31237, S2342) is performed in the office 14 days later. Because the debridement is related to the FESS, then it is also related to the septoplasty, and the 90-day global period applies to the post-operative sinus debridement.

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.

The problem comes from ambiguity in the definition of modifier 58 and 78. Modifiers 79 and (to a lesser extent) 59 compound the problem. There’s even justified confusion involving modifier 24. Using the wrong modifier can mean denied claims. Worse, most of the information currently available on the internet doesn’t exactly clarify the problem. Reviewing examples can be particularly helpful with ambiguous modifiers like this one. Here are some situations when modifier 58 would apply.

If a diagnostic endoscopic procedure results in the decision to perform an open procedure, both procedures may be reported with modifier 58 appended to the HCPCS/CPT code for the open procedure.  However, if the endoscopic procedure preceding an open procedure is a “scout” procedure to assess anatomic landmarks and/or extent of disease, it is not separately reportable.

Example 1

A patient undergoes an excision to remove a malignant lesion from his skin. This procedure includes a 10-day global period, and the surgeon plans to perform the closure on the 9th day. In this case, append modifier 58 to the closure code since it was a subsequent procedure related to the original procedure, and performed within the global period.

Example 2

A physician performs a debridement of a patient’s burn. The physician knows they will need to perform multiple debridements and makes sure to note this in the patient’s medical record. Every time the physician performs the additional debridements, he uses modifier 58.

Example 3

Another example of when to use modifier 58 would be 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). Bill CPT 19307-58 for the second procedure. Another postoperative period begins when the second procedure in the series is billed.

Inappropriate Usage of modifier 58:

  • 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 a retina, one or more sessions)
  • Reporting the treatment of a complication from the original surgery
  • Unrelated procedures during the postoperative period

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