General Surgery Coding Alert

When making a decision to apply modifier 58 for a subsequent procedure during the global period, you don't need to know if the patient returned to the operating room, or even if the surgeon planned the procedure at an earlier date. You need only know if the surgeon performed the initial and subsequent procedures for a related condition.

Choose 58 for -Go Beyond- Procedures

You may consider modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) for a procedure or service the surgeon performs during the postoperative period if the procedure or service is:

a) planned or anticipated (staged);

b) more extensive than the original procedure; or

c) for therapy following a diagnostic surgical procedure.

In each case, the subsequent procedure or service could be:

- related to the underlying problem/diagnosis that prompted the initial surgery, or/and

- anticipated at the time the surgeon performs the initial surgery

In other words: The patient's condition, rather than the results of a previous surgery, dictates the need for additional procedures, explains Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board. For procedures unrelated to the underlying condition prompting the initial surgery, or for an un-anticipated return to the operating room, you would select a modifier other than 58 (see below for more information).

Example: A patient may have had many prior abdominal surgeries that prevent the surgeon from immediately closing a recent hernia repair. Two weeks later, the surgeon is able to take the patient back to the operating room to close the wound.

In this case, the delayed closure had nothing to do with the hernia repair, but everything to do with the patient's underlying condition at the time of the surgery, Berman-Hvizdash explains. Therefore, you would report the closure with modifier 58 appended.

Look to documentation for a clue: Often, the physician knows up front that a procedure will have subsequent stages. In a best case scenario, the physician should acknowledge -- in his or her documentation -- the possibility that he or she will have to return to the operating room. This should give you a hint that you-ll need to apply modifier 58 in the subsequent procedure, Berman-Hvizdash notes.

The physician does not need to return the patient to the operating room (OR) to use modifier 58. The physician may provide a postoperative procedure or service, for instance, in his office or other outpatient setting, as long as the documentation clearly supports the need for the staged procedure, Berman-Hvizdash says.

A "more extensive" procedure to which you append modifier 58 doesn't need to be more complex or time-intensive than the original procedure (although it can be). Rather, the surgeon's subsequent procedure need only "go beyond" the work he or she performed during the initial procedure, affirms Jo Ann F. Kergides, CPC-H, physician services coder at UMDNJ-SOM Vascular Surgery in Stratford, N.J.

Here again, however, an related underlying condition -- not complications from the initial surgery -- must drive the decision to perform an additional procedure(s).

Example: The surgeon performs excision of the breast with minimal margins (19120, 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, one or more lesions). Later, the pathology report reveals malignant tissue. The surgeon must return the patient to the operating room to remove additional tissue and ensure that there is no remaining malignancy.

In such a case, you may report the follow-up procedure using the partial mastectomy code (19301, Mastectomy, partial [e.g., lumpectomy, tylectomy, quandrantectomy, segmentectomy]) with modifier 58 appended, Kergides notes.

Remember: Because the results of the first excision led to the decision to perform the partial mastectomy, you should report both procedures separately, according to CMS guidelines outlined in the national Correct Coding Initiative and elsewhere.

Example 2: The surgeon excises an ischial pressure ulcer with ostectomy. Several days later, she closes the operative wound using a muscle flap.

For the initial procedure (the excision), you should report 15946 (Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure).

You would claim the muscle flap closure at a separate session with 15734 (Muscle, myocutaneous, or fascio-cutaneous flap; trunk). Append modifier 58 to 15734 to show the payer that the closure during the global period was anticipated at the time of the initial procedure.

Tip: Modifier 58 does not reduce payment. The post-operative period, however, will reset from the date of the staged procedure, Berman-Hvizdash stresses.

You should not use modifier 58 if the patient needs a follow-up procedure because of surgical complications or unexpected postoperative findings that arise from the initial surgery, according to the AMA's CPT Assistant (vol. 18, issue 2, February 2008, page 3).

The follow-up procedure should arise because of an underlying condition present at the time of the initial procedure. This means that you should not use modifier 58 to describe treatment for a complication -- that is, for a different condition -- that arises as a result of or following an initial procedure, Kergides confirms. A complication, therefore, may be related to the initial procedure, but it is not related to the patient's initial condition.

For complications that require a return to the operating room (such as bleeding or infection), you should instead append modifier 78 (Unplanned return to the operating/procedure room by the same physician following an initial procedure for a related procedure during the postoperative period) to the subsequent procedure code.

Next Month: Complete instructions for modifier 78.