58 or 78

aguelfi

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I have a request for a refund on my desk for a patient who had a axillary node bx (38525 & 38792) abou 14 days after an excision an excision of breast lesion (19125). I used a 78 modifier because the op-note doesn't specify that the bx was a planned return to the OR, however I do see how it could be necessary to use a 58. We can't determine if the patient was going to return to OR until the results from the lesion removal are back. I'm interested to see what others think if they would use a 58, 78 or even something else. Should I appeal this?
 

mbort

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I would have used 58 because it was directly related to the outcome of the
pathology from the 1st surgery.


my two cents :)
Mary
 
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I'd use 58

I would have used 58 modifier ... while you didn't exactly plan the return to the OR, the surgeon knew that if the path report said X he would take the patient back for this second procedure.

I would definitely appeal.

F Tessa Bartels, CPC, CPC-E/M
 

dpeterson39

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If I refund it, shouldn't I just be able to rebill w/ the correct modifier?

I'd think twice before refunding the money as the first step. As for which modifier, I would call this a 58 situation. Instead of refunding, and as long as there is no contractual obligation stopping you; I would send a corrected claim with the Modifier 58 and request that they update their system to reflect the modifier change. The 58 modifier as depicted in the CPT Appendix A states that it is a staged or related procedure/service. Then it gives options a, b, and c to define where the procedure or service fits. I would call your scenario option b- "service is more extensive than the original procedure". Another great resource that explains the intent of CPT and HCPCS Level II Modifiers is Coding with Modifiers published by the AMA. The best rule of thumb with the 78 modifier is that a patient presents to the OR/Procedure Room unplanned with a complication steaming from the initial operative session.

Hope this is beneficial for you.
 
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