Procedure Coding: When To Use the 58 Modifier

Procedure Coding: When To Use the 58 Modifier

This is part of the Modifier Series, the articles include:

Deciding when to use modifier 58 requires precision in order to ensure this modifier is implemented correctly. Due to its vague description, coding staff are commonly unclear when modifier 58 should really be used, resulting in frustration and headache. Let’s start the clarification process by educating ourselves on what procedures and situations modifier 58 is actually meant for. Then, we’ll review clinical examples for context of when modifier 58 should apply during everyday use.

Defining Modifier 58

To start, modifier 58 is a surgical-specific modifier, used to indicate a staged or related procedure or service by the same physician during the postoperative period. Modifier 58 would apply 1) to a surgical service which the physician anticipates could take more than one session or 2) for therapy following the surgical service. A helpful tip to remember: if the additional procedure is because of the original condition that caused the global period, it is most likely to require modifier 58.

Here are the most important qualifiers for directing you toward modifier 58:

  • The subsequent procedure was planned, either at the time of the first procedure or prospectively;
  • The subsequent procedure was more extensive than the first procedure, either as part of the process or because the first did not have the desired outcome;
  • Or you need to indicate therapy after a diagnostic surgical procedure.

Clinical Scenarios

Reviewing examples can be particularly helpful with ambiguous modifiers like this one. Here are some situations when modifier 58 would apply.

Example 1
A patient undergoes an excision to remove a malignant lesion from his skin. This procedure includes a 10-day global period, and the surgeon plans to perform the closure on the 9th day. In this case, append modifier 58 to the closure code since it was a subsequent procedure related to the original procedure, and performed within the global period.

Example 2
A physician performs a debridement of a patient’s burn. The physician knows they will need to perform multiple debridements and makes sure to note this in the patient’s medical record. When the physician performs the additional debridements, use modifier 58.

Example 3
A patient undergoes a left breast biopsy and the physician diagnoses breast cancer. One week later, the surgeon performs a modified radical left breast mastectomy. The biopsy was the primary procedure resulting in a more extensive procedure, so the left breast mastectomy code would need a 58 modifier.

Of note, you can appropriately use modifier 58 when the physician did not plan the subsequent procedure, as long as it is more extensive than the first procedure.

Clear documentation is important

Each case, of course, requires surgical documentation and evaluation to demonstrate the intent of the treatment. Clear documentation is also necessary to explain that no other modifier would be more appropriate. For example, modifier 58 is often confused with modifier 78. This is understandable as they’re both surgical modifiers for repeat procedures. However, there is a distinct difference. Modifier 78 applies to surgical treatment for unplanned complications of a prior procedure. Clear, definitive documentation in the patient’s medical record will help eliminate any confusion as to why you appended modifier 58, and help prevent questions or delayed payment from payers down the line.

Summary

In surgical situations when a subsequent procedure takes place within the global period of the original procedure, and/or because the physician anticipated a planned (or staged) procedure, modifier 58 comes into play. Modifier 58 can still be applied when the subsequent procedure is unplanned, as long as it is related to the cause of the original procedure and is more extensive than the original. Be sure that no other modifier should apply, specifically modifier 78, since the two are easily confused. Clear, detailed patient treatment records are required in order to ensure payers have any questions answered quickly and efficiently and to avoid delayed reimbursement whenever possible.

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