Choose Which to Use: Modifiers 58, 78, or 79?
By Nancy Clark, CPC, CPC-I
Modifiers are critical to telling the story of your claim. Just as words with similar definitions convey distinct meanings (“plan” versus “scheme,” for instance), so do modifiers with similar descriptors. We’ll discuss three such modifiers that require precise application: 58, 78, and 79.
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.
A new global period begins with each subsequent procedure, and usually there is no reduction in reimbursement. Modifier 58 may be used during the global surgical period for the original procedure only. It may not be used for staged procedures when the code description indicates “one or more visits” or “one or more sessions.”
Note that 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.”
For example, a patient presents to the OR on May 1 for a cheek-to-nose skin flap. The operating surgeon performs the formation of a pedicle flap. The flap is formed and attached to the nose, maintaining the blood supply from the cheek. On June 1, the flap is divided and is permanently inset at the nose. Appropriate coding is:
May 1: 15576 Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral (90 global days).
June 1: 15630-58 Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips. Modifier 58 indicates that the procedure was planned prospectively. (Source: CPT® Assistant March 2010, volume 20, issue 3).
A new global period begins, and most payers will reimburse the second surgery based on 100 percent of the fee schedule.
A second example describes 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 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 female breast; 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.
In contrast to Modifier 58 (which involves a planned return to the OR), you should append 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 when treatment for complications requires a return to the operating or procedure room. In other words, the subsequent procedure represents an unintended outcome of the previous surgery. Examples include a post-surgical infection, debridement that requires a return to the OR, and hemorrhage after surgery.
Modifier 78 does not reset global days from the previous surgery, so the procedure usually is not reimbursed at 100 percent of the allowed amount (depending on the carrier’s guidelines). Some carriers reimburse only the intra-operative portion of the fee scheduled payment (usually 70-90 percent of the total). When applying modifier 78, the diagnosis is usually different for each procedure.
For example, on May 1 the patient undergoes a partial colectomy (90-day global period). On May 8, the patient is returned to the OR for treatment of partial dehiscence of the incision with secondary suturing of the abdominal wall.
Appropriate coding is:
May 1: 44140 Colectomy, partial; with anastomosis with 153.3 Malignant neoplasm of colon; sigmoid colon.
May 14: 49900-78 Suture, secondary, of abdominal wall for evisceration or dehiscence with 998.32 Other complications of procedures, not elsewhere classified; disruption of external operation (surgical) wound.
Note the use of different diagnoses.
Append modifier 79 Unrelated procedure or service by the same physician during the postoperative period to surgery codes to indicate that an unrelated procedure was performed by the same physician or a physician of the same specialty in the same surgical group during the postoperative period of the previous procedure.
The new procedure is usually linked to a different diagnosis. A new global period begins, and the new procedure should be reimbursed at 100 percent of the allowed amount, as determined by the carrier. Modifier 79 may override payer edits that would include this procedure as part of the previous surgery.
For example, on May 1 at 9:00 a.m., a patient presents to the OR for treatment of a closed fracture of the right ulna. Later that day, at 1:00 p.m., the patient presents to the emergency department (ED) with an uncontrollable nosebleed. The patient is returned to the OR, where the same physician repairs the posterior arterial hemorrhage with cautery.
Appropriate coding is:
9:00 a.m.: 25535-RT Closed treatment of ulnar shaft fracture; with manipulation with 813.22 Fracture of radius and ulna; shaft, closed; ulna (alone)
1:00 p.m.: 30905-79 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial with 784.7 Symptoms involving head and neck; epistaxis
In this instance, the diagnosis codes are different. You may also append modifier 79 to a subsequent surgery using the same diagnosis code.
For example, on May 1 the patient presents to the OR for a cataract removal on her right eye (90-day global). One month later (June 1), the patient presents to the OR for cataract removal on her left eye. The same surgeon performs both procedures.
Appropriate coding is:
May 1: 66984-RT Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) with 366.16 Cataract; nuclear sclerosis (nuclear cataract)
June 1: 66984-79-LT Left side with 366.16
Note the use of modifiers RT to indicate the right eye in the initial procedure, and LT to indicate the left eye in the subsequent procedure. The “paying” modifier, or the modifier that may affect payment (in this case, modifier 79), is listed before the HCPCS anatomical, or “informational” modifier.