Medicare Compliance & Reimbursement

If same condition prompts initial and follow-up procedures, 58 applies. The AMA revised CPT language for modifier 58 earlier this year and followed up by offering additional instructions on how to apply the modifier correctly. As in the past, however, to use this modifier appropriately you should be sure that the surgeon performs and documents a supplementary service during the global period of a related procedure. 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 is either (or both): • related to the underlying problem/diagnosis that prompted the initial surgery, or • 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. 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. 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 documentation -- the possibility that he or she will have to return to the operating room, which can give you a hint that you'll need to apply modifier 58 in the subsequent procedure. Place of Service Isn't an Issue 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. Don't Be Confused by 'More Extensive' 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, often, it can be). Rather, the surgeon's subsequent procedure
need only "go beyond" the work he performed during the initial procedure. Here again, however, the patient's condition -- not complications from the initial surgery -- must drive the decision to perform an additional procedure. Example: A patient undergoes surgery to remove a lesion from the base of the skull. The surgeon must also perform secondary repair of the dura to arrest the loss of cerebro-spinal fluid. The surgeon undertakes the surgical approach, lesion removal and primary closure (61580-61598 and 61600-61616, [...]