Cigna-Reimbursement for 'Staged' procedures using mod 58 breast reconstruction

[rubisaavedra]

Hi there,
does anyone have any idea if cigna reimburses 'less' for staged procedures using modifier 58 for breast reconstruction procedures following mastectomy?
I'm being told by the 'co-surgeon's' office that this is the case. Any input, would be appreciated. Thank you!

 

[danskangel313]

I couldn't find anything specific to Cigna about mod 58, but usually it pays at 100%.... however I did find this on Cigna's website:
https://cignaforhcp.cigna.com/publi...ia_breast_reconstruction_follow_mast_lump.pdf

If you go down to page 17, it says:
"Under this mandate, benefits for breast reconstruction services following mastectomy or lumpectomy must be provided to both men and women; a diagnosis of breast cancer cannot be required; and timing of breast reconstruction services is not a factor in coverage. In addition, the mandate prohibits any limitations to the number of prostheses or the length of time from the date of the mastectomy."

I interpret that to mean that the reconstruction (any stage of it) won't be considered global to the mastectomy, so I don't know that you'd need to use mod 58. I could be wrong, but it's worth looking into.

 

[mhstrauss]

I couldn't find anything specific to Cigna about mod 58, but usually it pays at 100%.... however I did find this on Cigna's website:
https://cignaforhcp.cigna.com/publi...ia_breast_reconstruction_follow_mast_lump.pdf

If you go down to page 17, it says:
"Under this mandate, benefits for breast reconstruction services following mastectomy or lumpectomy must be provided to both men and women; a diagnosis of breast cancer cannot be required; and timing of breast reconstruction services is not a factor in coverage. In addition, the mandate prohibits any limitations to the number of prostheses or the length of time from the date of the mastectomy."

I interpret that to mean that the reconstruction (any stage of it) won't be considered global to the mastectomy, so I don't know that you'd need to use mod 58. I could be wrong, but it's worth looking into.

I agree, mod 58 should not reduce reimburse. If there is a cosurgeon, you should only expect the cosurgery reduction.