General Surgery Coding Alert

2 case studies illustrate the meaning of a staged procedure

To use modifier -58 properly, you cannot simply label a postoperative procedures "staged" or "planned" after the fact because the surgeon realizes he is going to have to do more work. Rather, you must show that the surgeon planned a supplementary service, or that the supplementary service was required to complete treatment begun at an earlier date.
 
To better clarify proper use of modifier -58, consider two examples:

Case 1: Biopsy Followed by Mastectomy

You should apply modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) when a procedure or service during the postoperative period is:

 a) planned prospectively at the time of the original procedure (staged);
 b) more extensive than the original procedure, or;
 c) for therapy following a diagnostic surgical procedure, according to CPT guidelines.
 
In this first case study, the surgeon cannot necessarily anticipate the need for mastectomy at the time of the biopsy, but the mastectomy does qualify as a "more extensive" procedure that follows a diagnostic surgical procedure (the biopsy):
 
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) to examine an abnormal lump in the patient's right breast. The pathology report returns several days later and indicates the presence of a malignant tumor. To remove the cancerous tissue, the surgeon decides to perform a modified radical mastectomy (19240). The mastectomy occurs during the 90-day global period of the biopsy.

In this case, you should bill for the biopsy as normal, using 19120. Because the biopsy determined the need for the mastectomy - and because the mastectomy occurred during the global period of the biopsy - you should append modifier -58 to the mastectomy code 19240, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., in Brick, N.J.

Case 2: Diagnostic Scope With Open Procedure

Although surgical endoscopic procedures always include diagnostic endoscopic procedures, you can report a diagnostic endoscopic procedure separately with an open surgical procedure, according to chapter 1 of the National Correct Coding Initiative (NCCI).
 
To report the scope separately, however, you must:
 
a) show that the scope was purely diagnostic. If the surgeon uses the endoscope to "scout" the location of a lesion, for instance, or to confirm anatomic landmarks, or for any other nondiagnostic purpose, you cannot report the scope separately; and
 
b) append -58 to the follow-up open procedure.
 
In this second case study, the surgeon decides to perform a same-day open procedure based on the information provided by the diagnostic scope and, therefore, you may report both procedures separately.

The surgeon performs diagnostic sigmoidoscopy (45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Based on the results of the sigmoidoscopy, the surgeon immediately decides to perform a follow-up colectomy (44140, Colectomy, partial; with anastomosis).

You should report the sigmoidoscopy as usual, using 45330. In this case, because the colectomy was a follow-up procedure based on the results of the sigmoidoscopy, you should report 44140-58. Modifier -58 alerts the payer that the colectomy is the more extensive service that follows the diagnostic procedure, Cobuzzi says.
 
But 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 -58 to 44140, Cobuzzi adds.

'More Extensive' Doesn't Mean Complications

A "more extensive" procedure that calls for modifier  -58 is simply a procedure in which the surgeon "goes beyond" the work he performed during the initial procedure, says Marvel J. Hammer, RN, CPC, CCS-P, CHCO, owner of MJH Consulting in Denver.
 
Avoid the complications trap: Note also that the follow-up procedure should arise because of the same condition that prompted the initial procedure. This means that you should not use modifier -58 to describe treatment for a complication - that is, for a different condition that arises as a result of or following an initial procedure. A complication, therefore, may be related to the initial procedure, but it is not related to the initial condition, Hammer says.
 
For complications that require a return to the operating room, you should instead append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the follow-up procedure.