General Surgery Coding Alert

Unrelated services don’t count.

Coding subsequent procedures during the post-op period can be a challenge — but getting comfortable with a few modifies might save the day.

Specifically, learning when you can — and can’t — use modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) can clear the way to capturing all the pay your surgeon deserves for subsequent procedures.

Save 58 for ‘Planned’ Procedures

When your surgeon 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 either:

• planned or anticipated at the time of the original procedure
• more extensive than the original procedure
• for therapy following a diagnostic surgical procedure.

Pointer: Look to see when the surgeon first mentions the subsequent surgery — often in the original op note or when he knows the outcome/patient status immediately post-op.

Example: A patient has a malignant melanoma removed from his shoulder. The physician takes a lymph node biopsy (38510, Biopsy or excision of lymph node[s]; open, deep cervical node[s]). If pathology determines that the lymph node has metastatic malignancy, the physician plans to schedule the patient to come back for a lymph node dissection.

Code it: When the patient comes back in for the lymph node dissection (38500-38530 Biopsy or excision of lymph node(s); …), you will attach modifier 58 to that procedure code.

Explanation: “Use modifier 58 on the lymph node dissection because, when the physician takes the biopsy, he knows there is a chance that the patient may have to return for additional surgery,” says Robin E. Richards, CPC, a senior coder in Pittsburgh, Pa.

Another example: “In many plastic procedures, such as a breast reconstruction, there are a number of steps that must be performed in a specific order,” says Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CPCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. And those steps may require a planned return to surgery, which would necessitate using modifier 58.

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 a modifier on the second procedure.

For example: If your provider performs an excision by a needle and not a scalpel (38510) as in the previous example above, you need to report 38505 (Biopsy or excision of lymph node[s]; by needle, superficial [e.g., cervical, inguinal, axillary]). If the surgeon then performs the follow-up, staged lymph node dissection due to the pathology findings, you won’t need to attach 58 to that procedure code.