Orthopedic Coding Alert

Answer: There is no limitation in CPT for using modifier -58 (staged or related procedure or service by the same physician during the postoperative period) in the OR. In simplest terms, -58 is used on all subsequent procedures performed on the same problem as the original procedure, whether planned in advance or planned when the original procedure does not produce adequate expected results.

Modifier -78 (return to the operating room for a related procedure during the postoperative period) designates a return to the OR. This modifier was designed to address the Medicare policy for surgery on postoperative complications. Medicare makes special adjustments to the postoperative period for the subsequent surgeries in these situations and does not pay for procedures not performed in the OR for postoperative infections. So use -58 when just doing more work on the same problem whether in the OR, office or bedside. Use -78 when doing work in the OR for postoperative complications, and -79 (unrelated procedure or service by the same physician during the postoperative period) for a completely different problem in the postoperative period of another procedure.