General Surgery Coding Alert

Pre-planning exemplifies staged procedures.

You might lose the procedure pay you deserve if you fail to use modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) when you should.

Here’s why: Payers will bundle procedures performed during the post-op period of a prior procedure unless you provide a legitimate reason why they should not.

One of those legitimate reasons is if the second procedure was planned or anticipated at the time of the original procedure — and modifier 58 is the way to communicate that reason.

Study the following tips and examples to make sure you’re using modifier 58 to your advantage in your general surgery practice.

Know the Basics

You should use modifier 58 to indicate that the same physician performed a staged or related procedure during the post-op period, according to Catherine A. Brink, BS, CMM, CPC, CMSCS, president of HealthCare Resource Management Inc. in Spring Lake, N.J.

Tip: “Medicare does not require a return to the OR for the staged or related surgical procedure to be billable,” Brink says.

According to coding guidelines, modifier 58 applies when “the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure [staged]; b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure.”

Don’t miss the associated note: “For treatment of a problem that requires a return to the operating/procedure room … to surgically correct a complication of surgery … see modifier 78.”

Contrast: Use modifier 78 “when the patient returns to the OR during the global period of another related procedure for a complication or other unanticipated problem related to the initial surgery,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Wash.

Study Legit Modifier 58 Examples

Sometimes examples are worth a thousand explanations, so consider the following two scenarios:

Example 1: You surgeon performs a lumpectomy and also takes a sentinel lymph node biopsy of a deep axillary node. If the pathology report indicates metastasis to the lymph node, the surgeon intends to schedule the patient for a lymph node dissection. Two weeks later, the surgeon performs the axillary lymphadenectomy based on positive sentinel lymph node results.

Code it: For the initial procedures, report 19301 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)), 38525 (Biopsy or excision of lymph node(s); open, deep axillary node(s)), and +38900 (Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure)).

For the axillary lymph node resection two weeks later, report 38745 (Axillary lymphadenectomy; complete) with modifier 58, because the second procedure was planned prospectively based on the outcome of the original procedure that has a 90-day global period.

Example 2: The surgeon excises a 2.5 cm basal cell carcinoma of the face. The surgeon chooses to perform an adjacent tissue transfer to minimize scarring, but decides to wait for the pathology report to ensure clear margins before proceeding with the repair. Three days later, the surgeon performs the adjacent tissue transfer.

Code it: Report the initial excision as 11643 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm). Three days later, report the tissue transfer as 14040 (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less) with modifier 58.

Key: The excision has a 10-day global period, and the tissue transfer occurs during that time. Typically, the tissue transfer code includes the lesion excision. But because this is a staged procedure correctly identified with modifier 58, you should get paid for both procedures.