Urology Coding Alert

Check for planned vs. unplanned for guidance.

When considering whether to report modifier 58, don’t confuse it with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).

According to coding guidelines, modifier 58 applies when “the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure [staged]; b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure.”

And don’t miss the associated note: “For treatment of a problem that requires a return to the operating/procedure room… to surgically correct a complication of surgery…see modifier 78.”

Use modifier 78 “when the patient returns to the OR (operating room) during the global period of another related procedure for a complication or other unanticipated problem related to the initial surgery,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Wash.

Bottom line: The key to modifier 58 is that the return to surgery is planned; modifier 78 represents returns to surgery that were unexpected.