General Surgery Coding Alert

-More extensive- might not mean what you think When making a decision to apply modifier 58 for a subsequent procedure during the global period, you don't need to know if the patient returned to the operating room, or even if the surgeon planned the procedure at an earlier date. You need only know if the surgeon performed the initial and subsequent procedures for a related condition. Choose 58 for -Go Beyond- Procedures You may consider modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) for a procedure or service the surgeon performs during the postoperative period if the procedure or service is: a) planned or anticipated (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. In each case, the subsequent procedure or service could be: - related to the underlying problem/diagnosis that prompted the initial surgery, or/and - anticipated at the time the surgeon performs the initial surgery In other words: The patient's condition, rather than the results of a previous surgery, dictates the need for additional procedures, explains Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board. For procedures unrelated to the underlying condition prompting the initial surgery, or for an un-anticipated return to the operating room, you would select a modifier other than 58 (see below for more information). Example: A patient may have had many prior abdominal surgeries that prevent the surgeon from immediately closing a recent hernia repair. Two weeks later, the surgeon is able to take the patient back to the operating room to close the wound. In this case, the delayed closure had nothing to do with the hernia repair, but everything to do with the patient's underlying condition at the time of the surgery, Berman-Hvizdash explains. Therefore, you would report the closure with modifier 58 appended. Look to documentation for a clue: Often, the physician knows up front that a procedure will have subsequent stages. In a best case scenario, the physician should acknowledge -- in his or her documentation -- the possibility that he or she will have to return to the operating room. This should give you a hint that you-ll need to apply modifier 58 in the subsequent procedure, Berman-Hvizdash notes. Place of Service Isn't an Issue The physician does not need to return the patient to the operating room (OR) to use modifier 58. The physician may provide a postoperative procedure or service, for instance, in his office or other outpatient setting, as long as the documentation clearly supports the need for the staged procedure, Berman-Hvizdash says. Don't [...]