Gastroenterology Coding Alert

Clue: Complication procedures go with a different modifier.

When a patient takes another trip to the operating room during the global period, you owe your provider that extra code for the added service. But not all follow-up trips warrant a modifier 58. Bust your confusion by following this two-step guide.

Step 1: Keep Modifier Definition, Mandate Intact

According to CMS guidelines, you would use modifier 58 (Staged or related procedure or service by the same provider during the postoperative period) when a second surgery is performed in the postoperative period of another surgery when the subsequent procedure was:

• planned or "staged;"
• more extensive than the original procedure;
• for therapy following a surgical procedure; or
• for the reapplication of the cast within the 90-day global period.

In 2008, the American Medical Association (AMA) changed the description for modifier 58 to include the phrase 'planned or anticipated.' "This allows for a broader application in situations where the subsequent procedure is dependent on the outcome of the surgery. We are no longer limited to using this modifier only in situations where the additional procedures were planned ahead of time," explains Melissa Brown, RHIA, CPC, CPC-I, CFPC in her article Don't Let Modifiers Change Your Coding, published in January 2011 at the website Advance for Health Information Professionals.

The global period restarts with reporting the second (subsequent) procedure and modifier 58. Assuming your coding was accurate, the surgeon should receive 100 percent of the allowable reimbursement on both the first and the subsequent procedures.

Example: The surgeon performs diagnostic sigmoidoscopy. Based on the results of the sigmoidoscopy, the surgeon immediately decides to perform a follow-up colectomy. Report the following on your claim:

• 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the sigmoidoscopy
• 44140 (Colectomy, partial; with anastomosis) for the follow-up colectomy procedure
• Modifier 58 appended to 44140 to alert the payer that the colectomy is the more extensive service that follows the diagnostic procedure.

Caution: Because the sigmoidoscopy (45330) has zero global days, if the surgeon performs the follow-up colectomy on a different day, you would not need to append modifier 58 to 44140.

2. Pay Attention To Modifier 58's Limitations

When you have to deal with modifier 58, make sure the physician documents each stage of the surgery and your plans for returning the patient to the operating room for additional procedures to manage the patient's condition.

The "more extensive" clause in modifier 58's definition simply means a procedure in which the surgeon "goes beyond" the work he performed during the initial procedure. Also, you should not use modifier 58 to describe treatment for a complication. The follow-up procedure should arise because of the same condition that prompted the initial procedure, never a different condition. When a patient returns to the operating room for complications, you should instead append modifier 78 (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) to the follow-up procedure.