Otolaryngology Coding Alert

Procedures can be "related" in different ways. For example, Medicare considers treatment of a complication (e.g., wound infection) related to the original procedure. Other subsequent procedures or services may be related to the underlying condition that prompted the original surgery but are not, strictly speaking, related to the operation itself. The difference is significant from a coding perspective, because different modifiers should be used for each scenario.
 
Most procedures are part of a "surgical package" that also includes a global period, during which most additional procedures or services performed are considered part of the original procedure and not separately payable. Even procedures with zero global days (e.g., sinus endoscopies) have surgical packages, and most services provided on the day of or day before the endoscopy are included.
 
However, in many situations, services provided during the global period of another procedure are separately payable. For example, if the service provided is being performed because the patient has a separate problem that requires treatment, modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) should be appended to the appropriate CPT code when the service is reported.
 
In certain cases, related procedures may also be billed during a global period, but doing so correctly is trickier. Modifiers -58 (Staged or related procedure or service by the same physician during the postoperative period) and -78 (Return to the operating room for a related procedure during the postoperative period) include the term "related procedure" in their descriptors. The wording of the two descriptors can misdirect coders into believing that -58 is used when a service is performed in another location and that -78 is used when the second service occurs in the operating room.
 
Although -78 requires a return to the operating room, it is distinguished from -58 in many other, more significant ways. The most important is that the two modifiers are appended to services that are "related" very differently to an earlier procedure. The difference also explains why -58 reimburses at 100 percent, whereas -78 pays only the intraoperative portion of the procedure or service performed.
Modifier -58: Related to the Underlying Condition
Otolaryngologists often perform additional services that may be considered staged and/or more extensive procedures. CPT states that appending -58 indicates "that 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."
 
Modifier -58 is a "payment" modifier, which means that it prompts the carrier's software to override any edits and pay for the service. Use of this modifier must be monitored carefully, as misuse could draw unwanted attention, says Lee [...]