General Surgery Coding Alert

In each case, the subsequent procedure or service is either related to the underlying problem/diagnosis that prompted the initial surgery or anticipated at the time the initial surgery is performed (or both). The patient's condition, rather than the results of a previous surgery, dictates the need for additional procedures: Modifier -58 should not be used if subsequent procedures are necessary due to surgical complications or unexpected postoperative findings that arise from the initial surgery.

Modifier -78 (Return to the operating room for a related procedure during the postoperative period) also refers to "related procedure" in its descriptor. Unlike modifier -58, however, modifier -78 applies when the related procedure is undertaken as a result of conditions arising from the initial surgery, rather than from the patient's condition. Modifier -78 should be used only for complications arising from the original procedure although the term "complications" is conspicuously absent from CPT.

Note: When in doubt (i.e., the medical record does not clearly indicate the reason for the subsequent surgery), coders should check with the operating physician prior to selecting a modifier.

Modifier -78 requires that the patient return to the operating room (OR) and cannot be applied to procedures performed in a physician office or other outpatient setting. As stated above, for Medicare payers any complications of the initial surgery that may be handled without a return to the OR (e.g., routine infection, bleeding or perforation) are covered under the global period of that surgery.

Note that non-Medicare payers, i.e., payers that follow CPT, often stipulate different guidelines and therefore may reimburse for postsurgical wound debridement and other complications treated in the physician's office. Most commonly, a superficial infection at the incision may be resolved with a simple dressing change and antibiotics.