CODING Q&A

Zeroing in on Modifier 58

SUZANNE L. CORCORAN, COE • KIRK A. MACK, COMT, CPC, CPMA, COE

When you need to perform another surgery while in the global surgery period of a related procedure, how should you bill? This column examines the appropriate use of modifier 58 compared with modifier 78 for retina specialists.

Q. What is modifier 58?

A. According to CPT: “Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period.” It goes on to explain, “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.”

Q. What about modifier 78?

A. CPT defines modifier 78 as “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.” In explanation, CPT says “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.”

Q. What is the difference?

A. Both modifier 78 and modifier 58 might apply when a subsequent procedure is unplanned. The difference has to do with whether the second procedure is more extensive, and therefore of greater value, than the first procedure. Medicare uses relative value units (RVUs) assigned to each procedure to determine when a second procedure is greater than the first. Other payers often use RVUs as well. When a subsequent procedure is preplanned or staged, only modifier 58 applies.

Q. Do either modifier 58 or 78 affect payment rates?

A. Yes, in different ways. Modifier 78 indicates that the second procedure is related to the first, but not preplanned or staged, and of lesser or equal value. The global surgery period does not change; it continues from the date of the original procedure. Thus, reimbursement for the second procedure is reduced and only the intraoperative portion of the procedure is paid.

With modifier 58, the second procedure starts a new global period. In addition, payment for the second procedure is not reduced when using modifier 58 as it would be with modifier 78.

Q. Is the place of service an important distinction?

A. Yes. Modifier 78 applies only to procedures that require a return to the operating room (as defined by CMS), while modifier 58 does not impose a place-of-service requirement.

Q. What are some examples of correct usage of modifier 58?

A. Here are four to clarify this for you.

Example 1: Planned removal of silicone oil following vitrectomy

Silicone oil is injected in cases of a chronic retinal detachment, proliferative vitreoretinopathy (PVR), advanced cases of diabetic retinopathy, macular holes, and other disease processes that require long-term tamponade of the retina following vitrectomy. Once the eye appears stable or nearly so, the surgeon removes the silicone oil to avoid any long-term complications from the silicone oil. Surgeons often plan to remove the oil as the eye approaches stability. However, ultimate stability is not achieved until the final staged procedure — removal of silicone oil — is performed.

Coding for the procedure may vary depending on how it is performed; CPT 67036 or 67121 is most likely. If the oil is removed during the postoperative period, modifier 58 (staged procedure) is appended to the code. Start a new 90-day global surgery period for the second procedure; the new code is allowed at full value.

Example 2: Planned injections following vitrectomy

Intravitreal injections (CPT 67028) are used to treat multiple conditions — for instance, diabetic eye disease. When a patient undergoes a vitrectomy with internal limiting membrane peeling (CPT 67042) to treat residual diabetic macular edema, postoperative injections of anti-VEGF are not uncommon. The injections would be considered incidental or part of postoperative care and not billable unless they were preplanned. If the surgeon knows, at the time of the decision for vitrectomy surgery, that postoperative injections are likely, the injection(s) should be charted as preplanned.

In this example, the RVUs for 67028 are less than 67042, but the procedure was preplanned, which supports the use of modifier 58 to bill the injection in the postoperative period. Since the injection has zero postoperative days, the 90-day global period for 67042 continues to run from the date of the original procedure. The injection is allowed at full value and not reduced.

Example 3: Laser for a retinal tear followed by a retinal detachment repair

Unfortunately, some treatment modalities only fix a problem temporarily. A patient treated with laser for a retinal tear (CPT 67145) is one such example. One month later (within the global period) the patient returns with new signs and symptoms and is diagnosed with a retinal detachment developing from the previously treated retinal tear. The surgeon schedules a vitrectomy RD repair (CPT 67108) for the operating room.

In this case, the two problems — the retinal tear and detachment — are related. The RD repair was not “preplanned”; however, the RVUs for 67108 are greater than for 67145, making 67108 a more extensive procedure than 67145. As such, modifier 58 applies. Many offices confuse this issue and incorrectly apply modifier 78 since the services are related; in this case, lesser to greater takes priority. Start a new 90-day global surgery period for the RD repair; the new code is allowed at full value.

Example 4: RD repair with recurrent detachment and PVR/membrane peel

A surgeon performs a retinal detachment repair with vitrectomy (CPT 67108). During the 90-day global period, the patient develops PVR and a tractional detachment in the same eye. The subsequent repair — vitrectomy with membrane peeling for the recurrent detachment — is coded as 67113. The second procedure is not preplanned; the surgeon’s goal was for the original RD repair to be successful. However, 67113 is more extensive by RVUs than 67108, so modifier 58 applies. Start a new 90-day global surgery period for the second procedure; the new code is allowed at full value.

This same patient returns to the operating room in the global period a third time for a vitrectomy, membrane peel, and retinal detachment repair (CPT 67113). This time, modifier 78 applies, since the RVUs are the same (not greater). Modifier 78 does not extend the global surgery period from the second procedure, and payment for the third procedure is reduced. RP

All CPT codes are © the American Medical Association