Urology Coding Alert

Planning the procedure makes all the difference in your claim.

You might not report modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) as often as some other modifiers, but that doesn’t mean it is any less important to your reimbursement. Report it incorrectly and you will collect denials. But report it according to its intent and you will be glad you paid attention to the details.

Start with a Clear Understanding

As shown in its descriptor, modifier 58 applies to planned procedures, not unplanned. And that is the definitive factor in when – or when not – to append 58.

“Modifier 58 should be used to indicate that a staged or related procedure by the same physician is performed during the post-op period,” explains Catherine A. Brink, BS, CMM, CPC, CMSCS, president of HealthCare Resource Management Inc. in Spring Lake, N.J. “Its use indicates that the procedure you’re reporting with 58 was planned to be a ‘staged procedure.’”

“A new global surgical period begins with the use of modifier 58 on the staged or related surgical procedure,” Brink explains. “Medicare does not require a return to the OR for the staged or related surgical procedure to be billable.”

Important: A procedure may be considered to be staged preoperatively, during the initial surgery, or in the postoperative period depending on the clinical circumstances. In most instances a procedure to be considered staged must be prospectively planned as staged.

Test Your Knowledge in the Real World

Sometimes knowing whether a situation merits modifier 58 is more difficult than a quick glance at a chart will show. Let these three common scenarios posed by Urology Coding Alert readers and answered by Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook, help you in deciding when to append modifier 58.

Scenario 1:  The urologist performed a first stage PCNL (percutaneous nephrolithotomy) greater than 2 cm. The patient returned a week later for the second stage PCNL to fracture the remaining stone also greater than 2 cm.

Scenario 1 answer: A patient might sometimes have a very large stone that the physician is unable to completely fragment during a first single encounter. In that situation, the urologist will schedule a repeat procedure to complete the removal, as in this situation. You should report 50081 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm) as the correct procedure code for both encounters. On the claim for the second visit, append modifier 58 to 50081 to indicate that you are re-reporting the second stage of a procedure within the 90-day global of the first PCNL.

Scenario 2:  The urologist sees a patient within the global period for a related procedure such as an office cystoscopic removal of a double J stent.

Scenario 2 answer: You’ll report this procedure using 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple).

According to CMS, modifier 58 was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure whether the procedures are performed in the office or operative suite. Information in the Medicare Claims Processing Manual gives more details about reporting modifier 58, but does not indicate that the physician must return the patient to the OR before reporting modifier 58. Instead, the physician may provide a postoperative procedure or service, in his office or other inpatient or outpatient setting, provided that the documentation clearly supports the need for the staged procedure.

Because of this interpretation of modifier 58’s use, you should bill 52310 with modifier 58 when the urologist cystoscopically removes the stent in the office within the global period of an extracorporeal shock wave lithotripsy (ESWL) or PCNL (both of which have a 90-day global period).

Scenario 3: The urologist completed an extensive scrotal and left groin debridement for necrotizing fasciitis (the entire scrotum was removed). Twelve days later the physician did a second wound debridement and created bilateral testicular thigh pouches.

Scenario 3 answer: You will not need modifier 58 (or any other modifier) when reporting the second procedure because of two details. First, the initial debridement code 11004 (Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum) has a zero-day global period, so you can code any follow-up procedures separately without modifiers because no global period is in effect. Second, the wound debridement and pouch creation was not documented as a planned (or staged) follow-up procedure. You should report 54680 (Transplantation of testis(es) to thigh (because of scrotal destruction)) as the primary procedure and code 11004 as the secondary procedure as per their relative value units (RVUs).