Neurosurgery Coding Alert

Decide first if the procedure is related to or a complication of a previous surgery Can you easily distinguish between modifiers -58, -78 and -79? If not, you'll need to brush up on some modifier basics. Knowing when to apply each of these modifiers can mean the difference between complete reimbursement and costly claim denials. Select -58 for Related/Anticipated Procedures 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), or
b) more extensive than the original procedure, or
c) for therapy after a diagnostic surgical procedure. 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 surgeon performs the initial surgery (or both), according to CPT instructions.

In other words, the patient's condition, rather than the results of a previous surgery, dictates the need for additional procedures, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. You should not use modifier -58 if the patient needs a follow-up procedure because of surgical complications or unexpected postoperative findings that arise from the initial surgery. Place of Service Isn't an Issue The surgeon does not need to return the patient to the operating room (OR) to use modifier -58. The surgeon may provide a postoperative procedure or service, for instance, in his office or other outpatient setting.

Typically, you append modifier -58 to identify a staged procedure (a procedure that requires more than one operative session to complete). 

Here's an example: A patient undergoes surgery to remove a lesion from the base of the skull. The surgeon must also perform secondary repair of the dura to arrest the loss of cerebrospinal fluid.

The surgeon undertakes the surgical approach, lesion removal, and primary closure (61580-61598 and 61600-61616, as appropriate) during a single, extended operative session. The secondary repair, planned prospectively during the first session, generally occurs days later. You should use 61618 (Secondary repair of dura for CSF leak, anterior, middle or posterior cranial fossa following surgery of the skull base ...) to report this subsequent session with modifier -58 appended to indicate a staged procedure.

Don't Be Confused by 'More Extensive' A"more extensive" procedure to which you append modifier -58 doesn't need to be more complex or time-intensive than the original procedure (although it can be). Rather, the surgeon's subsequent procedure need only be more extensive than the work he performed during the initial procedure, says Kathleen Mueller, RN, CPC, [...]