Did you know that the rate at which you are reimbursed can depend upon whether you report a service with modifier 58 or 78? Yes, that is true. You are eligible for a 100% reimbursement rate when you perform planned or staged services.
Contrarily, you receive only a portion of the reimbursement when the return to the operating room was for a related procedure, but it was unplanned. This guide will help you understand everything you need to know about modifier 58’s accurate usage. So, continue reading and optimize your revenue cycle!
Modifier 58 – Description
Modifier 58 highlights to the insurance payer that a staged or related procedure was performed during the postoperative period of the first procedure by the same physician.
Appropriate Use Cases for Modifier 58
Let’s review a few real-world clinical scenarios where this modifier applies:
Staged Skin Grafting
Picture a 42-year-old female patient with a severe third-degree burn on her left arm. The surgeon performs an initial debridement. Besides, he documents in the operative report that the wound will require a split-thickness skin graft once the site is stable.
Therefore, three days later, during the global period of the debridement, the surgeon recalls the patient to the operating room. He then performs the planned skin graft procedure.
Here, you should apply modifier 58 to the skin graft procedural code 15100.
Escalated Breast Surgery
Assume a 26-year-old female patient who underwent a breast biopsy recently. The pathology comes back positive for malignancy.
Thus, the surgeon takes the patient back to the operating room during the postoperative period of the biopsy to perform a modified radical mastectomy.
Here, you should report a radical mastectomy (CPT code 19307) with modifier 58 because the second procedure was more extensive than the first.
Multi-Stage Eye Surgery
Imagine a 64-year-old male patient with a complex retinal detachment. He undergoes a vitrectomy with the injection of silicone oil. However, the physician’s treatment plan, documented at the time of the original surgery, mentions the planned removal of the oil once the retina has stabilized.
As a result, within the global period, the surgeon performs the planned removal of the silicone oil. Thus, you should bill the removal procedure covered under CPT code 67121 with modifier 58.
Accurate Usage Guidelines for Modifier 58
The following are some essential usage guidelines to ensure the accurate usage of this modifier:
Understand When to Use Modifier 58
Listed below is the key criterion for appending this modifier:
- The surgeon anticipated the need for a follow-up or subsequent procedure.
- The physician performs a minor procedure, and the results indicate that a more extensive procedure is required within the global surgical period.
- When a diagnostic procedure leads to the decision to perform a therapeutic procedure within the global period, append 58 to the therapeutic service.
Know When NOT to Append It
If you want to steer clear of audit risks and penalties, beware of misusing or overusing modifier 58. Here’s when you should avoid using it:
- In scenarios where a patient develops an unexpected complication. Use modifier 78 instead.
- When the second procedure is unrelated to the first surgery, 58 does not apply. Use modifier 79.
- Do not use it if the procedural code description already includes multiple stages.
- Never append it to the first surgery in a series. That is, it only applies to subsequent procedures performed during the global period.
Fulfill Documentation Requirements
Detailed documentation is your best defence against denials. Thus, ensure to include the following when reporting a service with modifier 58:
- The original operative notes should explicitly state the plan for staged services.
- The subsequent notes must clearly link the new service back to the original procedure to establish that it is not an unrelated and unplanned event.
- In cases where the second procedure is more extensive, the documentation must justify the need for the higher-level code.
Modifier 58 vs. 78
The table below offers an at-a-glance view of the differences between modifiers 78 and 58:
| Modifier 78 | Modifier 58 | |
|---|---|---|
| What Does It Indicate? | Unplanned return to the operating room for a related procedure during the postoperative period. | Staged/related procedure by the same physician during the postoperative period. |
| Core Intent | Unplanned complications, e.g., a hemorrhage or infection, required a return to the operating room. | Planned or anticipated, i.e., the procedure was expected, a natural progression, or more extensive than the first. |
| Global Period | The original postoperative clock continues. | Starts a new global period. |
| Impact on Payment | Usually reimbursed only for the intraoperative portion, i.e., approximately 80%. | Reimbursed at 100% of the allowable fee schedule. |
Are you still confused about which modifier to append? Ask yourself, when the surgeon finished the first procedure, did they know they might need to perform the second procedure?
If the answer is affirmative, append 58. Otherwise, use modifier 78.
Final Thoughts
With that said, it must now be clear when you should and should not use modifier 58. But before we bid adieu, just remember some key pointers!
First, the second procedure must be planned and related to the first surgery. Second, note that upon billing the second procedure, the global period resets. Third, modifier 58 allows you to secure 100% reimbursement for the second procedure. And finally, it is always appended to the second procedure’s CPT code when the procedure was performed in the global period of the first procedure by the same physician.
Hopefully, these details will help you get it right every time. However, if you still struggle, feel free to outsource medical billing and coding services to professionals like NeuraBill.
