CODING CORNER

Which Surgical Modifier Should I Use?

Understanding the Definition and Use of -58, -78 and -79.

BY JOY WOODKE, COE, OCS

Modifiers are confusing — particularly identifying the appropriate modifier to use when additional surgery is performed within the global period. To determine the correct modifier, most commonly 58, -78 or -79, there are different factors to consider, such as:

›› Was the additional surgery related or unrelated to the first surgery?

›› Was the second surgery planned or unplanned?

›› Was the procedure considered therapy following a major surgery?

The answers to these important questions will help guide your selection of the appropriate modifier. Here is a review of the definition of each of these modifiers, including specific case studies.

Note: The HCPCS eye modifiers (RT or LT) should follow the CPT modifiers 58, 78 and 79.

58 MODIFIER

Modifier -58 is defined as a staged or related procedure by the same physician during the postoperative period. Here are three definitions for use:

1. More extensive than the original procedure (lesser to greater)

2. Necessity of a procedure was determined and documented preoperatively (pre-planned)

3. For therapy following a surgical procedure.

According to the three definitions, this modifier is appropriate for cases that have been planned or unplanned, yet are always related to the first surgery. When using the -58 modifier, a new postoperative period begins. Reimbursement is 100% of the allowable.

CASE STUDY #1

Two weeks status-post pneumatic retinopexy in the left eye (CPT 67110), a repair of retinal detachment with vitrectomy, gas and laser is performed on the same eye (CPT 67108). Based on the lesser to greater rule (the 67108 is a more extensive procedure than the 67110), the modifier -58 is appropriate.

CASE STUDY #2

During the 3-day post-op visit after a pneumatic retinopexy in the right eye (CPT 67110), the patient is scheduled for a laser in the same eye. Review of the exam notes prior to the pneumatic retinopexy revealed the laser treatment was pre-planned and documented. Appending the -58 modifier to the CPT 67105 is appropriate.

CASE STUDY #3

Patient presents 1 month status-post vitrectomy with endolaser panretinal photocoagulation (CPT 67040) for vitreous hemorrhage and proliferative retinopathy. Upon examination, it is determined that the patient needs an intravitreal injection of anti-VEGF medications for diabetic macular edema. Because an injection in the global period is considered therapy, appending a -58 modifier to the CPT 67028 is advised.

78 MODIFIER

When an unplanned return to the operating or procedure room by the same physician for a related procedure in the global period is performed, the -78 modifier should be used. Furthermore, the related surgery is for an unanticipated clinical condition. The reimbursement for these cases are based on the pre- and intra-operative services only and paid at 80% of the allowable. As a result, a new post-operative period does not begin.

CASE STUDY

One week status-post vitrectomy to remove a vitreous hemorrhage (CPT 67036), the patient is seen for an increase in intraocular pressure. An anterior chamber tap is performed (CPT 65800), subsequently a -78 modifier is used, as this treatment was for an unanticipated condition.

79 MODIFIER

The -79 modifier, by definition, is an unrelated procedure performed in the global period. The surgery can be either planned or unplanned, and a new post-operative period would begin. Similar to the -58 modifier, the reimbursement is at 100% of the allowable.

Typically, the unrelated procedure is performed in the global period of the opposite eye, in a different anatomical site, or when an unrelated diagnosis is treated.

CASE STUDY

During the global period of a diode focal laser in the right eye for wet macular degeneration (CPT 67210), a laser to repair a retinal tear in the left eye is performed (CPT 67145). Being that the opposite eye is now the one treated, a -79 modifier would be correct to append.

CONCLUSION

Mastering modifier use starts with identifying the appropriate questions to ask. Whether the case is related, planned or more extensive will assist you in choosing the correct modifier. Reviewing these questions along with understanding the guidelines for use are the keys to success. NRP

Ms. Woodke is an administrator with Oregon Eye Consultants, LLC.