General Surgery Coding Alert
Proper Use Explained
The modifier -58 descriptor in CPT 2001 specifies:
The physician may need to indicate that the performance of a procedure or service during the postoperative period was a) planned prospectively at the time of the original procedure; b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure.
Although each of the above applies in some situations, none comprehensively defines when modifier -58 should be used, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill.
For example, the surgeon performs an excisional biopsy of the breast (19120, excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19140], open, male or female, one or more lesions). This biopsy has a 90-day global period. The pathology report, which returns a few days later, indicates the presence of a malignant tumor. The surgeon decides to perform a modified radical mastectomy (19240). When the mastectomy is billed, modifier -58 is appended to 19240 to indicate that it is a staged procedure and should not be included in 19120's 90-day global period.
In this case, the modified radical mastectomy was not preplanned (although it is still staged) because, had the biopsy returned negative, it would not have been performed. Modifier -58 may be used, however, whether the procedure is preplanned or not.
Some coding specialists have attempted to clarify the situation by advising that modifier -58 be used when the second procedure is related, not to the first procedure, but to the underlying condition that prompted both procedures.
For example, after a limb amputation on a patient with diabetes mellitus, healing may be difficult because the diabetes can cause peripheral vascular problems, such as poor circulation. In some cases, a further amputation of the same limb may be necessary. Modifier -58 is correctly attached to the second amputation -- not because it is staged, but because it is related to (but not a complication of) the first amputation (i.e., poor healing after the first procedure led to the second), says Cathy Klein, LPN, CPC, a coding and reimbursement specialist in Indianapolis.
But modifier -58 is not appended because the second procedure is related to the same underlying disease process as the first, Klein says. She points out that if the same patient required an amputation of a different limb, the two amputations would be considered unrelated, and therefore modifier -79, not modifier -58, would be correctly appended to the appropriate amputation code -- even though the underlying disease process (i.e., diabetes mellitus) ultimately caused both procedures to be performed.
Another correct use of modifier -58 for a related procedure involves an emergent procedure on a patient with a perforated colon. In such cases, there is no bowel preparation, and when the surgeon opens the patient the intestinal contents spill throughout the abdominal cavity. The area, therefore, is contaminated, and any subsequent dbridements or incision and drainage (I&D) performed within the 90-day global period of the original procedure (e.g., a colectomy) are reported with modifier -58 appended to show they are related to the original surgery.
Similarly, if the surgeon performs a deep I&D on a patient with a perirectal abscess, and two days later the wound is infected and the surgeon dbrides it (at the patient's bedside), modifier -58 is appropriately used, Mueller says.
"Surgeons lose a lot of money by thinking these dbridements are included in the I&D's global period because they are complications and the patient isn't returned to the operating room [which would permit use of modifier -78]. But the infection is not a complication. The wound did not become infected as a result of the surgery. It was already inherently infected. Therefore, modifier -58 is appropriate," she says.
Because the contamination and subsequent infection are not a complication of this surgery, modifier -78 should not be used. This modifier, which was introduced because Medicare includes complications from surgery in the global period unless a return to the operating room (OR) is required, is more appropriately used for postoperative bleeds or infections that result from the surgery itself. If the complication is treated anywhere other than the OR, Medicare (but not all private payers) consider the service part of the original procedure's global package.
Note: When modifier -78 is used, only the intra-operative portion of the procedure is reimbursed. When modifiers -58 or -79 are used 100 percent of the procedure's relative value units, including preoperative and postoperative components, are payable.
If the second procedure is unrelated and modifier -79 is used, a different diagnosis is required. For example, the surgeon performs a modified radical mastectomy and axillary node dissection (19240). The patient then sees an oncologist, who recommends chemotherapy. Because the patient's peripheral veins cannot handle the delivery of the chemotherapy, the same surgeon who performed the mastectomy is asked to implant a venous access device (36533). The insertion of the device is unrelated to the mastectomy, and therefore is billed with modifier -79. A different diagnosis (venous insufficiency, 459.89) is linked to 36533, Mueller says. She adds that breast cancer may be included as a secondary diagnosis.
Finally, Klein notes, the surgeon should indicate in the procedure notes if the procedure was (1) planned or staged, (2) a complication from initial surgery, or (3) unrelated due to a mitigating factor (i.e., poor veins). "As usual, the more information the surgeon documents, the better the chance of the claim being reimbursed and surviving any subsequent audit," she says.
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