CODING Q&A

Appropriate Use of Modifiers 58 and 78

ANSWERS PROVIDED BY RIVA LEE ASBELL

Q. My fellow surgeons and I are having a hard time grasping when to use modifier 58 — and when to use modifier 58 vs modifier 78. Could you provide us with some relevant clinical examples?

A. Let’s begin with taking a look at the 2 modifiers.

Modifier 58 has 3 distinct uses. All of these only apply when the subsequent procedure is performed within the global period of the first procedure. The modifier is placed on the bill on the subsequent procedure(s). Examples of procedures that are planned prospectively at the time of the original procedure, also known as a staged procedure, would be severing of the eyelids after a Hughes procedure in oculoplastics; removal of silicone oil after retinal detachment repair with its use; laser treatment following TpA injection.

The second use is when the second procedure is more extensive than the original procedure. Think of this as moving up the food chain from lesser to greater.

Clinical examples would include (1) performing a pneumatic retinopexy followed by repair with a buckle; (2) retinal detachment repair with vitrectomy followed by retinal detachment repair with vitrectomy and epiretinal membrane peeling; (3) repair of retinal detachment by scleral buckle followed by repair of retinal detachment with vitrectomy.

The third use is for therapy following a diagnostic procedure, such as biopsy followed by lesion excision and vitreous tap followed by vitrectomy.

Modifier 78 is the related modifier — think of it in terms of complications. If you are doing the same or a lesser procedure than the original one (you can think of this as going down the food chain), you are in a modifier 78 situation. If you are dealing with a complication and using the same CPT code as used originally, you should use modifier 78. Thus, a retinal detachment rep air by vitrectomy followed by a second retinal detachment repair by vitrectomy would take modifier 78.

Modifier 78 requires a return to the operating room (defined by Medicare as an OR in a hospital or ambulatory surgery center, an endoscopy suite, or a laser suite). If your laser is in a patient examination room you cannot bill for procedures performed there with a modifier 78. It must be a dedicated laser room.

Here is a complicated example from my Retina Reimbursement Workshop:

A female patient had a history of previous surgery for repair of full thickness macular hole in the left eye, which was repaired with vitrectomy and insertion of silicone oil.

The silicone oil was subsequently removed 8 weeks later. She then developed a recurrent tractional retinal detachment with vitreoretinal organization within the global period of the silicone oil removal. The patient also had a significant cataract.

Current surgery consists of limbal incision for the phacoemulsification cataract extraction with insertion of an IOL, a repeat pars plana mechanical vitrectomy with additional membrane peeling, endodiathermy, temporary injection of liquid perfluorocarbon, air-fluid exchange, air-perfluorocarbon exchange, scatter laser photocoagulation, internal drainage of subretinal fluid, silicone oil injection, all of the left eye. Code for all procedures.

Diagnosis:

1. 361.81 Tractional retinal detachment with vitreoretinal organization, left eye
2. 366.10 Cataract, left eye

Surgery:

Diagnosis: 1) 1

Procedure: 67038 Vitrectomy with epiretinal membrane peeling

Modifier(s) -58-LT

Diagnosis 2) 1

Procedure: 67108 Repair of retinal detachment with vitrectomy, scleral buckle

Modifier(s) -51-58-LT

Diagnosis 3) 2

Procedure: 66984 Phaco/cataract extraction

Modifier(s) -51–79-LT

(Note: modifier -79 is used on the third code since it is unrelated to the original surgery)

A final word of caution — modifier 58 engenders a new global period where modifier 78 does not. Your billing people need to keep track of that coding element.

CPT codes copyright 2006 American Medical Association. RP