Medicare Compliance & Reimbursement

Look for plan or expanded procedure to justify 58 modifier.

All the world may be a stage, but not every surgery is staged. To make sure your surgeon is using the 58 modifier correctly, you should be checking that the second procedure has the proper relationship to the first.

Many coders find the 58 modifier, for staged or related procedures during a global period, intimidating.  "It has several components, and sometimes you're not sure if the procedure you are working with fits in exactly," says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, TN.

Ask yourself two things: "Did we plan on doing this in stages? Or is this procedure more radical than the prior procedure?" advises Barbara Cobuzzi, president of CRN Healthcare Solutions in Tinton Falls, NJ. The 58 modifier came about because CPT wanted to encourage physicians to do conservative care, leading to more radical care if necessary.

The 58 modifier "was originally proposed for surgeons who did a lumpectomy of the breast followed by a mastectomy," notes Maxine Lewis with Medical Coding & Reimbursement Management in Cincinnati, Ohio.

Tip: Check the operative report for the original surgery to see if the doctor planned it in stages, suggests Lisa Center, physician billing specialist and coder with Mt. Carmel Regional Medical Center in Pittsburg, KS. Verify with the surgeon that the procedure was staged or related before appending the 58 modifier.

Example: One of Wilkinson's clients recently performed a biopsy of part of the sigmoid colon, and it came up malignant. A couple of days later, the physician went back and removed the whole lesion. "With a biopsy, the doctor had at least a possible expectation that he'd have to go back in and do more extensive surgery," Wilkinson says.

Another example would be a diabetic patient with gangrene, who had a foot removed, and then a few days later had the entire lower leg amputated, Wilkinson adds.

Or a patient might have third degree burns all over his body, and the doctor may know that sequential debridements will be necessary. Even if the doctor doesn't state the need for sequential debridements in the history and physical, you can infer it from the clinical information in the chart almost every time, says Wilkinson.

You should be able to tell if a procedure is "related" from looking at the notes, Wilkinson adds.

Gray area: If a patient has an uneventful surgery and then has an infection of the incision line a few days later, is that "related?" If the physician performs an incision and drainage at bedside, the need for this service is certainly due to the original surgery, notes Wilkinson. But to stay on the safe side, you'd probably [...]