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Modifier 58 versus 78

  1. #1
    Default Modifier 58 versus 78
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    Scenario patient has aortic valve replacement and 2 vessel CABG, 4 days later they have to re-do the procedure they decide to leave the patients chest open after the re-do. 2 days later patient is doing great they go in and close the chest up.

    My thinking is the 58 staged or related procedure is the most appropriate for the closure.

    I have 2 other coders saying it should be the 78 unplanned return trip.

    Any advice is greatly appreciated.


    Laura, CPC, CEMC

  2. #2
    Columbia, MO
    use the 78, the 58 as a staged procedure, means the second procedure is more extensive than the first which s not the case in your scnario.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    For the re-do ... did they know or plan on re-doing it?? If so, use 58. I don't consider it more extensive... If it was not planned, use 78.

    The closure is definitely 58.
    Last edited by ARCPC9491; 08-21-2009 at 09:49 AM.

  4. #4
    The re-do was not planned, the patient did good for 24-48 hours then starting declining, they did the echo then another TEE it showed severe aortic insufficiency so they went back to the OR re-did the procedure and left the site open incase they had additional issues.

    My understanding of 58 is it is any one of the reasons listed, not all, so it would have been planned to close him at some point and therefore it is a staged procedure.

    Upon further investigation, the closure was done in the patients ICU room, they just brought the operating room unit over to do it. Now I am sure 78 is not appropriate but I am thinking they don't get to bill for the closure at all as it was included in the procedure itself.

    Thanks for your responses to the original question and I am hoping someone can confirm or deny billing for the closure done at beside.

    I agree with the 78 for the re-do, it is the closure that I am questioning.

    Laura, CPC, CEMC

  5. #5
    Columbia, MO
    If the closure was performed at the bedside then I say it is not billable as it is was not a return to an or or procedure room. But even as I write this I remember from way back where I was told if documentation supports that the patients condition prohibited moving them to the OR for a procedure during the global then you would use the documentation to support that the intent was to use the OR so you would append the 78. So I would let the documentation guide that one.

    Debra A. Mitchell, MSPH, CPC-H

  6. Default
    Hi Laura,

    Per the STS, you would use the -58 for the chest closure. It was planned, they kept the chest open knowing they would need to go back to close it.

    There are two reasons for a -58 modifier:
    1. if it is a staged procedure or
    2. if it is a procedure that is related to the first one but more extensive.

    As for the bedside closure, if the patient is Medicare, you cannot bill for this. Medicare only allows for procedure performed in an OR during the post-op period. If the patient has commercial insurance, I say bill it.

    Lisi, CPC

  7. #7
    Default Thanks everyone
    I really appreciate everyone taking time to help me out with this one.

    Laura, CPC, CEMC

  8. Default
    This is the case of 78 modifier not the 58 modifier. Physician normally performed CABG along with Valve replacement. in 5-10% graft blocked within 24 hours and patient developed symptoms or valve does not open properly then physician redo the procedure.


    Vikas Maheshwari
    MBA-Healthcare Services, CPC-H

  9. #9
    I appreciate the input Vikas.

    The question isn't on the 2nd procedure, its on the 3rd, when they closed 2 days after the second procedure.

    I agree the 2nd trip to the OR is correct with a 78. The problem I have it after the 2nd surgery they left the chest open and covered with an Ioban dressing. 2 days later patient is doing good so they close up the chest. This procedure was billed with a 78, which I believe is incorrect. After further investigation I found out they didn't even take the patient back to the OR, they did the closure in his room.

    My ultimate conclusion is it would be inappropriate to bill anything for the closure in this case.


    Laura, CPC, CEMC

  10. #10
    I would do a -58 for the delayed closure

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