General Surgery Coding Alert

Patients often require additional services following a procedure. CPT includes three modifiers that may be used when both the original procedure and the subsequent service take place in the operating room, including:
Modifier -58 -- staged or related procedure or service by the same physician during the postoperative period
Modifier -78 -- return to the operating room for a related procedure during the postoperative period
Modifier -79 -- unrelated procedure or service by the same physician during the postoperative period   Choosing the proper modifier is difficult, in part because the descriptions of modifier -58 is not easily understood and in part because there is significant confusion about what constitutes a "related" procedure. As a result, many surgeons attach the wrong modifier when reporting services performed during the postoperative period of an earlier procedure.
The modifier -58 descriptor in CPT 2001 specifies:
The physician may need to indicate that the performance of a procedure or service during the postoperative period was a) planned prospectively at the time of the original procedure; b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure.   The descriptor does not precisely define a related procedure or explain how such a procedure differs from one that is more correctly appended with modifier -78. This has led to several conflicting theories on the correct use of modifier -58, such as:
It should only be used for staged procedures.
It should only be used when the second procedure is related to the underlying disease process, not to the prior surgery.
It should only be used when the second procedure is more extensive.
Although each of the above applies in some situations, none comprehensively defines when modifier -58 should be used, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill.   Defining a Staged Procedure   Of all the situations for which modifier -58 may be used, the most easily understood -- and the most common -- is the staged procedure. Staged procedures may be preplanned, depending on the circumstances and the patient's condition. 
For example, the surgeon performs an excisional biopsy of the breast (19120, excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19140], open, male or female, one or more lesions). This biopsy has a 90-day global period. The pathology report, which returns a few days later, indicates the presence of a malignant tumor. The surgeon decides to perform a modified radical mastectomy (19240). When the mastectomy is billed, modifier -58 is appended to 19240 to indicate that it is a staged procedure and should not be included in 19120's 90-day global period.
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