Wiki Use of Mod 58

[skorkfranks]

Patient originally had TLIF performed at L5-S1 with PEEK cage inserted.

Two weeks later the patient returns because of migration of the PEEK cage. Surgeon performs an arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar (22558) as well as a laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar(63042).

My question is since this is a complication, but a reexploration is performed, can I bill 63042 with a modifier 58?

Thanks.

 

[purplescarf23]

I would bill -78. Generally billing -58 indicates that this was a 'planned' return to the O.R. and I am assuming this was not.

58-Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.

78-Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.)

Kelsey, CPC, CEMC

 

[skorkfranks]

Thanks. That was the feeling I had since it was a complication of the cage slipping. Just needed to see it in writing since I'm sure the Doc will probably question it.