Thursday, August 26, 2010

Medicare modifier 58 and appropriate usage

Modifier 58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Definition:

• Indicates a staged or related procedure or service by the same physician during the postoperative period

Modifier “-58” (Staged or related procedure or service by the same physician during the post-operative period) was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure. Modifier “-58” indicates that the performance of a procedure or service during the post-operative period was:

• Planned prospectively or at the time of the original procedure;

• More extensive than the original procedure; or

• For therapy following a diagnostic surgical procedure.

Modifier “-58” may be reported with the staged procedure’s code. A new post-operative period begins when the next procedure in the series is billed.


Modifier Definition Comments


• Modifier 58 indicates the procedure was:

- Planned prospectively at the time of the original procedure

- More extensive than the original procedure.

- For therapy following a diagnostic surgical procedure.

• Append modifier 58 to the code for the subsequent procedure performed

• Documentation should support the procedure performed

• Modifier 58 should not be reported if the subsequent procedure is clearly unrelated to the original surgery


• A new global period is initiated

Instructions

    The same physician planned, at the time of the original surgery/procedure, a return trip to the operating or procedure room within the 10 or 90 day post op days

Correct Use

    Treatment of problem requiring a return to the operating/procedure room
        More extensive than original procedure
        Unanticipated clinical condition
        Therapy following a diagnostic, surgical procedure                              
    Each case requires surgical documentation and evaluation
    Modifier 58 appropriate for example; hardware removal was planned as part of therapeutic approach involving multiple, staged procedures to the surgical intervention
    Physicians in the same specialty, same group are to bill and are reimbursed as a single physician
    Use modifier 78 for treatment problems unplanned requiring return trip to operating room
        If hardware removed in unplanned surgery return for a complication, (e.g. infection of the wound site or rejection of the hardware itself), modifier 78 appropriate

Incorrect Use

    Not appropriate for E/M or assistant surgery services

Claim Coding Example

    Patient has excision (11606) with a 10 day global and a complex repair closure (13101) planned 9 days after the surgical date, then append modifier 58 to the closure.


CPT Modifier 58 – Staged or Related Procedure or Service by the Same

Physician during the Postoperative Period

The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure;

or c) for the therapy following a diagnostic surgical procedure. This circumstance must be reported by adding the CPT modifier 58 to the staged or related procedure.

Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See CPT modifier 78.

Appropriate Usage:

• To report a staged procedure planned at the time of the original procedure
• When the staged procedure is more extensive than the original procedure
• For therapy following a diagnostic surgical procedure
• When performing a second or related procedure during the postoperative period.

Inappropriate Usage:

• Appending the modifier to ASC facility fee claims
• Appending the modifier to a procedure with XXX global period on the MPFSDB
• Appending the modifier to services listed in CPT as multiple sessions, (i.e. 67208, Destruction of localized lesion of retina, one or more sessions)
• Reporting the treatment of a complication from the original surgery that requires a return to the operating room
• Unrelated procedures during the postoperative period

Modifier 58 Definition - Indicates a staged or related procedure or service by the same physician during the postoperative period


Facts:

• A new postoperative period begins when the next procedure in the staged procedure series is billed.
• Staged procedures do not apply to claims for assistant at surgery or services of an ASC.
• Used during the post-operative period starting the day after the initial procedure.


Definitions Modifier 58

Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: The physician may need 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 diagnostic surgical procedure. This circumstance may be reported by adding the modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating/procedure room (eg. unanticipated clinical condition), see modifier 78.

The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for the therapy following a diagnostic surgical procedure. This circumstance must be reported by adding the CPT modifier 58 to the staged or related procedure.

Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See CPT modifier 78



Coding Guidelines

When modifier 58 is used, the staged relationship to the original surgery must be documented in the medical record. This does not necessarily mean that the final decision to perform the subsequent surgery or the date it will be performed is known at the time of the original surgery. “Decisions to perform subsequent procedure(s) may depend on the outcome of the surgery and the patient's postoperative status. The term anticipated was added [to the description for modifier 58] because physicians can anticipate the potential for subsequent procedure(s) but cannot always predict it.”

Modifier 78 may not be used with place of service 11 (office). Modifier 78 requires a return to the operating room or procedure room (e.g. Cath Lab, Interventional Radiology Procedure Room, Endoscopy Room).


Documentation requirements

Indicate performance of a procedure or service  during the postoperative period:

• Planned prospectively at the time of the original  procedure (Staged)

• More extensive than the original procedure; or

• For the therapy following a diagnostic surgical  procedure

Purpose To define when the Plan recognizes services appended with Modifier 58.

Scope Applies to all Company lines of business and products with the exception of Medicare Advantage.

Policy The Plan recognizes Modifier 58 appended to a service to indicate a staged or related planned procedure was performed during the global period of the initial surgical procedure by the same physician who performed the initial procedure. Appending modifier 58 to another surgical service breaks the global period of the first procedure and resets the global period based on the subsequent staged procedure.

Documentation in the member’s medical chart or records should indicate prospective plans for returning the patient to the operating room for additional procedures during the global period of the initial surgery.

Modifier 58 should not be used on procedure codes which indicate in their description “one or more sessions”. These codes are defined by CPT as consisting of one or more subsequent sessions and the Relative Value Units (RVUs) attached to such codes already reflect the multiple sessions.

When it is necessary to indicate that a basic procedure or service was repeated by the same physician or other qualified healthcare professional subsequent to the original procedure or service, modifier 76 should be added to the service.

For treatment of a problem or complication that requires an unplanned return trip to the operating room for a related surgical procedure during the postoperative period, modifier 78 should be added to the service.

For treatment of a problem or complication that requires an unplanned return trip to the operating room for an unrelated surgical procedure during the postoperative period, modifier 79 should be added to the service.

Modifier 58 is never billed with modifier 78 or 79 on the same service.

Modifier 58 scenario 1

• New global period begins with each subsequent procedure

• Used only during the global surgical period for the original procedure

• Cannot be used for staged procedures when the code description indicates "one or more visits” or “one or more sessions” • CPT Descriptor Note: “For treatment of a problem that requires a return t th ti difi 78” to the operating room use modifier 78”

Modifier 58 Coding Scenario 2

More extensive than original procedure

• Diagnostic procedure and subsequent surgery Diagnostic procedure and subsequent surgery

• May 1st, Code:

• 19120-RT, Removal of breast lesion, (90 global days)

• Diagnosis: (239.3) Neoplasm of unspecified nature, breast

We are confused after researching the definitions of modifiers -58 and -78. Which modifier, if any, should we use?

ANSWER: Note the following descriptions for the modifiers in question:

• Modifier -58: Staged or related procedure or service by the same physician during the postoperative period

• Modifier -78: Unplanned return to the operation/procedure room by the same physician following initial procedure for a related procedure during the postoperative period

The biggest difference between these two modifiers is that modifier -58 indicates a planned procedure whereas modifier -78 indicates an unplanned procedure. Consider the following example: Dr. Jones performs a lumpectomy on Mary’s right breast on October 1. After the pathology report comes back, Dr. Jones schedules Mary back into the procedure room because the lab shows the margins are too close.

You would report the procedure code for the lumpectomy again, with modifier -58 because this fits this modifier’s description, specifically in that it is more extensive than the original procedure.

Having to return to the procedure room because of close margins is always a possibility when performing a lumpectomy, so this also supports the planned or at least anticipated aspect of the second procedure, supporting the use of modifier -58.


• Unlike the “-78” modifier, the original procedure global period gets reset (“begins anew”) with the “-58” modifier use. In most cases, payers allow 100% of the total fee schedule allowance.


• It is critical, if you are going to use the “-58” modifier under its “staged” option, to document prior to performance of the procedure, the need for staging additional procedures or the possibility that additional procedures will need to be performed to achieve the ultimate surgical goal.

• The “-58” modifier is not used when there is a complication of the original surgery requiring a return to the operating room.

• Modifier “-58” procedures are not required, but may be performed in an operating room.


Modifier 58 definition and rule: 

Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Description:

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. Note:  For treatment of a problem that requires a return to the  operating/procedure room (e.g., unanticipated clinical condition), see modifier 78.

This modifier can be located in the following rule(s):

** Global Procedure Days/Package
** Global Maternity
** This modifier can be used to override an edit.


Modifier 58 has been removed from manual review.

The Home Health Agencies Manual has been renamed to Home Health Services. This name change update was made in the two affected Utah Medicaid Provider Manuals: Physical Therapy and Occupational Therapy Services and Rural Health Clinics and Federally Qualified Health Centers Services


“Staged or related surgical procedures or services that are performed during the postoperative period may be reimbursed when they are billed with modifier 58. A postoperative period will be assigned to the subsequent procedure. Documentation must indicate that the subsequent procedure or service was not the result of a complication or any of the following:

• It was planned at the time of the initial surgical procedure.
• Is more extensive than the initial surgical procedure.
• It is for therapy following an invasive diagnostic surgical procedure.”

The correct information is: 

Documentation must indicate that the subsequent procedure or services were not the result of a complication and any of the following:• It was planned at the time of the initial surgical procedure.

• Is more extensive than the initial surgical procedure.
• It is for therapy following an invasive diagnostic surgical procedure


Staged or Related Procedures Guidelines.


Modifier “-58” was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure. This modifier is not used to report the treatment of a problem that requires a return to the operating room.

The physician may need to indicate that the performance of a procedure or service during the postoperative period was:

a. Planned prospectively or at the time of the original procedure;
b. More extensive than the original procedure; or
c. For therapy following a diagnostic surgical procedure.

These circumstances may be reported by adding modifier “-58” to the staged procedure. A new postoperative period begins when the next procedure in the series is billed

Exclusions from Prepayment Edits

A/B MACs (B) exclude the following services from the prepayment audit process and allow separate payment if all usual requirements are met: Services listed in §40.1.B; and Services billed with the modifier “-25,” “-57,” “-58,” “-78,” or “-79.” Exceptions See §§40.2.A.8, 40.2.A.9, and 40.4.A for instances where prepayment review is required for modifier “-25.”

In addition, prepayment review is necessary for CPT codes 90935, 90937, 90945, and 90947 when a visit and modifier “-25” are billed with these services.

Exclude the following codes from the prepayment edits required in §40.3.B. 92002 92004 99201 99202 99203 99204 99205 99281 99282 99283 99284 99285 99321 99322 99323 99341 99342 99343 99344 99345

In addition, the limitation of liability provision (§1879 of the Act) does not apply to these determinations since they are fee schedule reductions, not denials based upon medical necessity or custodial care. Claims for surgeries billed with a “-22” or “-52” modifier, are priced by individual consideration if the statement and documentation required by §40.2.A.10 are included. If the statement and documentation are not submitted with the claim, pricing for “-22” is it the fee schedule rate for the same surgery submitted without the “-22” modifier. Pricing for “-52” is not done without the required documentation.

Separate payment is allowed for visits and procedures billed with modifier “-78,” “-79,” “-24,” “-25,” “-57,” or “-58.” Modifier “-24” must be accompanied by sufficient documentation that the visit is unrelated to the surgery. Also, when used with the critical care codes, modifiers “-24” and “-25” must be accompanied by  documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed. 

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