Sunday, May 1, 2011

cpt modifier 58 with example

Modifier 58 – Staged/related procedure by the same physician during a postoperative period

The following rules apply:

•    Apply modifier 58 to surgical procedures that were (a) planned or anticipated at the time of the original surgery, (b) more extensive than the original procedure, or (c) for therapy following the original procedure.
•    The new surgical procedure usually involves a new CPT® or HCPCS code.
•    Do not apply modifier 58 to procedures whose definitions include the description “one or more sessions” (such as, 67105) if the subsequent sessions are performed during the postoperative period of the initial session. Modifier 58 may only be used with these types of procedure if a subsequent session is performed outside of the postoperative period of the original procedure.
•    The planned surgical procedure starts a new global period.
•    Do not report modifier 58 with modifiers 78 or 79.
•    Modifier 58 is an information modifier

Example

On February 1, a patient undergoes an iridotomy (66761) on his left eye. In the medical record, the surgeon states the patient may need a laser trabeculoplasty on the same eye. On April 10, the patient sees the doctor for a follow-up visit, and the surgeon decides to perform the second surgery the next day. The trabeculoplasty is billed as 65855-58-LT.


Intraoperative Services

The article incorrectly stated that:

“Physicians who performed a surgical procedure with a 10- or 90-day global period but do not render postoperative services must bill the surgical procedure code with the modifier 54. Modifier 54 indicates that the surgeon is relinquishing all of the postoperative care to a physician outside of the same group.”

The correct information is:

Physicians who performed a surgical procedure with a 10- or 90-day global period but do not render postoperative services must bill the surgical procedure code with the modifier 54. Modifier 54 indicates that the surgeon provided the surgical care only.

The article incorrectly stated that: “Co-surgeons may be reimbursed for surgical procedures that are billed with modifier 62 if the Texas Medicaid fee schedule indicates that the procedure allows for co-surgeons. Claims will be suspended for manual review of the documentation of medical necessity.“

The correct information is:

Co-surgeons may be reimbursed for surgical procedures that are billed with modifier 62 if the Online Fee Lookup (OFL) indicates that the procedure allows for co-surgeons. Claims will not suspend for a manual review of the documentation of medical necessity.

Postoperative Services

The article incorrectly stated:

 “E/M services that are provided by the same provider forreasons that are unrelated to the operative surgical procedure may be considered for reimbursement if they are billed with modifier 24. The submitted documentation must substantiate the reasons for providing E/M services.

•     Modifier 24 must be billed with modifier 25 if a significant, separately identifiable E/M service that was performed on the day of a procedure falls within the postoperative period of another unrelated procedure. The postoperative modifier should always be billed before any other modifiers.

•     Modifier 24 must be billed with modifier 57 if an E/M service that was performed within the postoperative period of another unrelated procedure results in the decision to perform major surgery.”

The correct information is:


•     Modifier 24 may be billed with modifier 25 if a significant, separately-identifiable E/M service that was performed on the day of a procedure falls within the postoperative period of another unrelated procedure. The postoperative modifier should always be billed before any other modifiers.

•     Modifier 24 may be billed with modifier 57 if an E/M service that was performed within the postoperative period of another unrelated procedure results in the decision to perform major surgery. The article incorrectly stated that:

“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


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),

Billing examples

Staged or prospectively planned procedure: Sternal debridement (21627) is performed for mediastinitis, and it is noted that a muscle flap repair (15734) is needed subsequent to the sternal debridement to properly close the defect. Procedure code 15734 with modifier 58 appended should be submitted since the muscle flap repair was planned at the time of the initial surgery (staged).

More extensive than the original procedure: A surgeon treats a diabetic patient with advanced circulatory problems. The initial surgery results in three gangrenous toes being amputated from the patient’s left foot, and is billed Amputation, toe; metatarsophalangeal joint 28820-T1, 28820-51-T2, 28820-51-T3. During the postoperative period it becomes necessary to amputate a portion of the patient’s left foot. Procedure code 28805, Amputation, foot; transmetatarsal, with modifier 58 appended should be submitted since the partial amputation of the left foot is more extensive than the original procedure.

For therapy following a diagnostic surgical procedure: An incisional prostate biopsy (55705) is done, and the specimen returns from the pathologist as “positive CA of the prostate”. Within the 10-day follow up period of the prostate biopsy, a radical perineal prostatectomy with bilateral pelvic lymphadenectomy is performed. Procedure code 55815 with modifier 58 appended should be submitted since the therapy followed a diagnostic surgical procedure.

• Modifier 58 is appended to major and minor surgical procedures only. It is not used on evaluation and management (E/M) codes.

• Modifier 58 is not used with procedure codes that are described as “one or more services”. These procedures are considered multiple sessions or are otherwise defined as including multiple services. In these instances, the code should be reported one time for the entire treatment period, regardless of the number of services required to complete the procedure. Reimbursement for these “multiple session” codes is based on the sum of the total procedures. Therefore, separate reimbursement will not be made for each segment of the procedure, even if it is for more than one service. (Refer to Coding Guidelines.)

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