Ophthalmology and Optometry Coding Alert

Question: One of our ophthalmologists performed a retinal detachment repair (67107), and just two weeks later the same patient returned because the retina re-detached in the same location as the first, and we repeated the same procedure. Should we append modifier -58 for a procedure done during the postoperative period?
      
Ohio Subscriber

Answer: Under these circumstances, appending modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to the retinal detachment repair code (67107, Repair of retinal detachment; scleral buckling [such as lamellar scleral dissection, imbrication or encircling procedure], with or without implant, with or without cryotherapy, photocoagulation, and drainage of subretinal fluid) seems logical.
 
However, you can't use modifier -58 simply because you are performing another procedure to fix a recurring problem. You must meet one of three criteria to use modifier -58:
  1. The subsequent surgery planning takes place at the time of the original procedure (staged).
  2. The subsequent surgery is more extensive than   the original procedure.
  3. The subsequent surgery is for therapy following a diagnostic surgical procedure.

The example above does not meet the first criterion because the physician did not plan for the retina to detach again. It does not meet the second criterion because the first and second procedures would be valued the same. The third criterion also does not apply because the initial surgical procedure was not diagnostic. You cannot append modifier -58 to code 67107 a second time under these circumstances. 
 
When you do not meet the criteria for modifier -58, and the second or more expensive procedure is performed in an operating-room setting during the postoperative period of the first procedure, append modifier -78 (Return to the operating room for a related procedure during the postoperative period).
 
Remember that when you use modifier -78, the post-operative period does not restart; for major procedures, the period will end 90 days following the date of the first surgery.
 
If the second procedure had been greater (valued higher on the Medicare fee schedule), such as 67108, (Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique), then -58 could be appended to 67108 and the postoperative period would restart.
 
Also, according to CMS, you can't use modifier -58 with any procedures whose descriptors indicate "one or more sessions," regardless of whether they are planned.