Wiki spine surgery

[rbn_hampton@yahoo.com]

hello, the doctor does spine surgery he does the anterior first and flip the pt over and do the posterior of the spine. do i use a 58? the other coders say yes. this was planned. but it is not documented in the report. I thought i use a 58 when the doctor come back a day or longer not on the same day.

 

[Rebecca Leeper]

Separate Notes?

Is your provider documenting the additional procedure in a separate note? If it is in a separate note and noted as 1st portion, and 2nd portion of surgery, use the 58 Modifier. If it is all in one note use the 59 to indicate separate distinct sites/approach. This is how I have done it for my provider for some time now.