Otolaryngology Coding Alert

You won't have to take a leap of faith when using modifiers 58 and 78 in the new year. CPT 2008 takes the gray out of these modifiers with several wording revisions.

Revisions to modifiers 58 and 78 should make distinguishing between the two modifiers easier. Modifiers 58 and 78 "were previously used interchangeably due to inadequate distinction between them," explains the AMA in CPT Changes 2008: An Insider's View.

Protocol: Choose the correct modifier based on these guidelines:

- modifier 58: warrants some level of planning or anticipation

- modifier 78: reserve for procedures that are unplanned and not foreseen in advance.

When your otolaryngologist performs a procedure that is staged or related to the global postoperative period of another procedure, you may use modifier 58 (Staged or related procedure or service by the same physician during the postoperative period). Identifying a staged surgery that the surgeon planned has always been straightforward.

Example: An otolaryngologist places a trans-tracheal oxygen (O₂) therapy tube. On day 1, the otolaryngologist performs a tracheostomy (31610, Tracheostomy, fenestration procedure with skin flaps). On day 2, during the second step of the procedure, the physician moves the O₂ cannula of the long-term O₂-use patient from the nose to the trachea (31730, Transtracheal [percutaneous] introduction of needle wire dilator/stent or indwelling tube for oxygen therapy).

You code: Because the tracheostomy code (31610) used on day 1 has a 90-day global period, "we code 31730 with modifier 58 to let payers know we planned the tube placement at the time of initial service," says Karla M. Westerfield, business manager at Southeast Wyoming Ear, Nose & Throat Clinic PC, in Cheyenne.

Look for these documentation clues that signal modifier 58's applicability. "During any global period, if the treating physician uses language that indicates that further procedures are scheduled during the global period as a related procedure," modifier 58 applies, Westerfield says.

Whether you should count second surgeries that are unplanned in the surgeon's mind but still staged has been more contentious. Solution: CPT 2008 redefines "staged." The 2007 wording for modifier 58 defines staged as "planned prospectively at the time of the original procedure (staged)," Westerfield says. The new 2008 wording states a staged procedure is "planned or anticipated (staged)."

The difference: "Prospective means -expected or likely,- and anticipated means -to look forward to,- " Westerfield says. The AMA may have made this change to try "to more plainly state the reasoning" preceding a staged procedure, she says.

Impact: Modifier 58 will apply to staged or related procedures that were "planned or anticipated" at the time of the original surgery, not just ones that your doctor planned in advance. Many coders were already using modifier 58 when the doctor only anticipated the possibility of surgery instead of planning it, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, consulting director of education for The Coding Institute in Naples, Fla. This change will just make those coders "more comfortable" with that usage, she says.

Anticipated surgeries ---ones that are unplanned but obviously staged -- involve a lesser procedure that results in a more complicated one. "Part of the reason behind 58 is to encourage surgeons to practice conservative care leading to more extensive care," Cobuzzi says.

For instance, an otolaryngologist does a lobectomy (60220, Total thyroid lobectomy, unilateral; with or without isthmusectomy), hoping that the procedure will remove the patient's cancer. The pathology report shows that the lobectomy did not remove the entire malignancy. During 60220's 90-day global period, the surgeon performs a completion thyroidectomy (60260, Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid).

In this case, you would use 58 on the completion thyroidectomy: 60260-58, Cobuzzi says. Although the surgeon didn't say that he would do a total thyroidectomy, he anticipated that a more extensive procedure might be necessary. Therefore, the second procedure, which involves more work than the original procedure, is staged.

For treatment of an unanticipated clinical condition that requires a return to the operating room (OR), you should instead use modifier 78. CPT 2008 stresses that the modifier is for an "unplanned procedure following initial procedure" in the modifier's revised guidance. The modifier's definition also adds "unplanned," "procedure room" and "by the same physician" to read in 2008: "Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period."

"Modifier 78 means an unexpected, unplanned return to the OR [or procedure room] by the same physician," Westerfield says. In the above O₂ tube placement scenario, "31730 is not done in an OR and is planned at the time of the initial procedure." Therefore, modifier 78 would be inappropriate.

Instead: Turn to modifier 78 when a complication prompts a surgeon to take a patient back to the operating room, Cobuzzi says. Medicare will only pay for a surgical complication that requires a return to the operating room, meaning it qualifies for modifier 78.

During the 90-day Medicare global period for 42826 (Tonsillectomy, primary or secondary; age 12 or over), a 68-year-old Medicare beneficiary has severe post-tonsillectomy hemorrhaging. The otolaryngologist is unable to control the bleeding and treats the patient in the operating room.

Solution: You should use modifier 78 on the bleed control code 42962 (Control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; with secondary surgical intervention): 42962-78. Because the tonsillectomy complication required the surgeon to return to the OR for surgical intervention, modifier 78 is appropriate. The modifier breaks the carrier's global period edit for 42826.