Gastroenterology Coding Alert

Get the staging right by scanning the op notes.

Choosing the right modifier to represent the clinical situation when you are coding subsequent procedures during the postoperative period can be a challenge. Make your job easier by becoming comfortable with modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period).

Continue reading to learn when you should attach modifier 58, and see how it differs from other postoperative procedure modifiers.

Start by Learning How to Use Modifier 58

When your physician performs a procedure or service during the postoperative global period of a prior procedure, you’ll need a modifier to prevent the payer from bundling the reimbursement into the original procedure’s pay. Turn to modifier 58 when the second service was:

• Planned or anticipated at the time of the original procedure

• More extensive than the original procedure

• For therapy following a diagnostic surgical procedure.

Pointer: When you read, in the medical record, that the physician anticipated a subsequent surgery or procedure, a red flag should go up that you need modifier 58. Look for when your physician made the decision. The surgeon may make the decision for a subsequent surgery at the time of the original surgery or once the surgeon knows the outcome of the surgery and the status of the patient.

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

• 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) 

• 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 physician performs the follow-up colectomy on a different day, you would not need to append modifier 58 to 44140. 

Avoid Attaching the Wrong Modifier

Be careful when it comes to choosing the most accurate modifier for surgical procedures during the global period. Make sure you don’t confuse modifier 58 with 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) or 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period). 

“I think the 58 modifier is underused because people are quick to go directly to the 78 and 79 postoperative modifiers,” Richards adds.

Bottom line: Use modifier 58 when the provider knows or suspects that another related procedure is necessary during the postop period. In contrast, use modifiers 78 or 79 when there is an unanticipated postop condition, related or not, requiring the patient return to the operating room during the postop period.

Additionally: Look at the global period of the initial procedure code. If the initial procedure has a 0-day global period, which does not have a postop period, you do not need modifier 58 on the second procedure.