Orthopedic Coding Alert

Question: To append modifier 58, does the procedure have to meet all three of the criteria listed in CPT Appendix A?
Minnesota Subscriber

Answer: CPT's view is that you don't have to meet all the criteria. You need to meet only one.

Here's why: CPT Appendix A's full description for modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) includes the instruction that you may use the modifier to indicate that a procedure or service's performance -during the postoperative period was (a) planned or anticipated (staged); (b) more extensive that the original procedure; or (c) for therapy following a surgical procedure.-

Key point: The use of the word -or- indicates that you only need to meet one of the criteria.

The AMA's Feb. 2008 CPT Assistant also specifies that you don't have to meet all the criteria. In fact, any of the criteria above (a-c) or performance during the original surgery's postoperative period may -reflect the staged or related procedure or service,- CPT Assistant states. Generally experts suggest using modifier 58 when the surgeon anticipates the subsequent surgery within the global period.

Mod 58 example: The surgeon performs incision and drainage (28003, Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas) for a patient with a severe toe infection and leaves the wound open, planning to observe the infection to decide if she must amputate. Two days later, the surgeon determines that she must amputate the third toe (28820-58, Amputation, toe; metatarsophalangeal joint). She leaves the site open to allow the infection to clear. Four days later, the surgeon performs a secondary closure (13160-58, Secondary closure of surgical wound or dehiscence, extensive or complicated). Note modifier 58 appended onto the codes for anticipated services 28820 and 13160.