Modifier 58 or 78?
Compare and contrast these modifiers to ensure proper use.
Modifiers are necessary for complete and accurate coding. They convey important information about a claim and directly affect reimbursement. But choosing the most appropriate modifier can be confusing — especially when two or more modifiers have similar descriptors. For example:
Modifier 58: Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period
Modifier 78: Unplanned return to the operating room/procedure room by the same physician or other qualified health care provider following initial procedure for a related procedure during the postoperative period
Let’s compare these two modifiers to ensure their proper use.
Note Similarities and Differences
Both modifiers are for use only during the postoperative or global period. Both affect the global period, and directly affect reimbursement.
We typically look to modifier 58 to indicate an expected return to the operating room to complete a procedure in stages. By contrast, we look to modifier 78 if the return to the operating room is unplanned. But an unplanned return to the procedure room may still call for modifier 58.
CPT® Appendix A tells us that modifier 58 may be used to indicate a procedure that is:
Planned or anticipated (staged);
More extensive than the original procedure; or
For therapy following a surgical procedure.
Do not use modifier 58 when the physician is treating a complication of a previously-performed procedure. That is a job for modifier 78.
Clarify What “More Extensive” Means
An example of a more extensive procedure might occur for a patient with a traumatic injury such as a wound. The original procedure is debridement and cleaning up the wound. Five days later on follow up, the physician notes the wound is not healing well and repeats a more extensive debridement. Modifier 58 is appropriate in this example, even though the repeat procedure was unplanned. The patient is not having a complication that necessitates a return to the procedure room, but the original “less extensive” procedure simply wasn’t enough. We are still treating the condition. We aren’t treating a problem resulting from the original procedure.
To continue the above example, five days after the second debridement the patient returns with pain, swelling, and infection. In this case, it’s appropriate to use modifier 78 because the patient is having complications from the original procedure.
Don’t Let Reimbursement Rule Your Decision
Modifier 58 breaks the original global period and starts a new global period. Modifier 78 does not.
Use of modifier 78 results in a reduction of payment. Modifier 58 allows full payment. Refer to the table to see how the modifiers affect payment:
|Modifier 78||Modifier 58|
|It does not break the original global period. The global period from the initial procedure is still in effect.||It breaks a global period and starts a new one.|
|Use of modifier 78 results in a payment reduction based on the individual payer’s fee schedule.||Use of modifier 58 will result in full payment.|
|The subsequent procedure is unplanned.||The subsequent procedure is planned or staged or is more extensive than the initial procedure.|
|The subsequent procedure is done because of a complication from the initial procedure.||The subsequent procedure is not for a complication.|
|Modifier 78 requires a return to the operating room or endoscopy suite.||Modifier 58 does not require a return to the operating room.|
Ask yourself these two questions when selecting between modifiers 58 and 78:
- Are we treating the original condition more extensively, in stages, or providing therapy? If so, use modifier 58.
- Are we treating a complication of the initial surgery? If so, use modifier 78.
Remember to select modifiers based solely on the documentation. Don’t be tempted to select them based on how they affect reimbursement.
Lashel Church, CPC, CPC-I, CPB, CPPM, CEMC, is the department head for Perry Technical Institute’s medical technology programs. She teaches the Medical Office Administration & Coding classes at Perry Tech. Prior to teaching, Church held positions in billing and coding. She is a member of the Yakima, Wash., local chapter.