Urology Coding Alert

Trap: Don't think 58 is just for advanced planning

Still confused about which postsurgical modifier to use on claims despite the CPT Codes 2008 revisions? You're not the only one.

Despite the fact that CPT 2008 revised the text explaining modifier 58 (Staged or related procedure or service by the same physician during the postoperative period), many practices are still confused about how to interpret modifier 58 and when to use it rather than modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period).

Move beyond the confusion and ensure you're coding every postsurgical procedure correctly with these expert tips.

Tip 1: Don't Rely on Planning

This year, CPT advised that you may append modifier 58 to staged or related procedures that were "planned or anticipated" at the time of the original surgery -- not just ones that your surgeon planned in advance.

Caution: The new description doesn't mean that you should automatically apply modifier 58 to all foreseen secondary procedures and append modifier 78 for unplanned postsurgical procedures.

Bottom line: You should apply modifier 58 when a procedure or service during the postoperative period is:

• planned prospectively at the time of the original procedure (staged), or

• more extensive than the original procedure, or

represents surgical treatment following a diagnostic surgical procedure.

"The current procedure has some connection to the original procedure, be it a more extensive approach to the original procedure or planned services after the original procedure (surgery or therapeutic treatment)," says Edwina Sprow, CPC, owner of Sprow Consulting Services based in Phoenix.

Example: The urologist performs a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH). Because of the large size of the prostate gland, the initial procedure is incomplete, and in his op note, the urologist indicates that the patient will need a second-stage TURP to remove more tissue at a later date. The patient returns to the operating room 41 days later for another TURP because of the persistent BPH.

In this case, you report the first TURP using 52612 (Transurethral resection of prostate; first stage of two-stage resection [partial resection]). Then, because the urologist said that the patient would require a second- stage resection during the 90-day global period of the first resection, you should code the second TURP as 52614 (Transurethral resection of prostate; second stage of two-stage resection [resection completed]). Append modifier 58 to indicate a staged procedure and ensure full payment for the second TURP within the 90-day global of the first.

Important: Payers require that documentation in the initial op note should indicate that a second staged procedure will be necessary. This prospectively indicates the anticipated staged procedure.

Key: The patient's condition, rather than the results of a previous surgery, dictates the need for additional procedures. You should not use modifier 58 if the patient needs a follow-up procedure to correct surgical complications that arise from the initial surgery.

Tip 2: OR Isn't a Requirement

Your urologist does not need to return the patient to the operating room (OR) for you to use modifier 58, says Denae M. Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw, Mich. The physician may provide a postoperative procedure or service, for instance, in his office or other outpatient setting. In all cases, however, the same physician must provide both the initial service/procedure and the follow-up procedure that requires modifier 58.

Tip 3: 'More Extensive' Doesn't Equal More Complex

Don't be confused by "more extensive": A "more extensive" procedure to which you append modifier 58 doesn't need to be more complex or time-intensive than the original procedure (although it can be). Rather, the urologist's subsequent procedure need only be more extensive than the work he performed during the initial procedure. Here again, however, the patient's condition -- not complications from the initial surgery -- must drive the decision to perform an additional procedure.

" 'More extensive' is an important set of words," Merrill says. "What they are talking about is when a patient first has a simple-type procedure and that doesn't 'fix' the problem, so they take the patient back for a more complex-type procedure."

Explanation: Modifier 58's descriptor refers to when the patient undergoes a procedure that fails to completely correct the problem, and then the patient requires a more extensive procedure during the global of the first procedure. An example would be an extracorporeal shock wave lithotripsy (50590) that does not completely fragment a renal pelvic calculus followed by a "more invasive" procedure, a percutaneous nephrostolithotomy (50081), to completely fragment and remove the stone. The proper coding would be 50590 and 50081-58.

Important: If you're using modifier 58 due to "more extensive" reasons, ensure that your urologist has clearly documented the reasons in the additional procedure's note, Sprow says.

Tip 4: Turn to 78 for Complications

Unlike modifier 58, you should apply modifier 78 when conditions arising from the initial surgery (complications) -- rather than the patient's condition -- call for a related procedure.

Example: The urologist performs a distal ureterectomy, ureteroscopy and ureteral reimplantation of the left ureter for a lower ureteral carcinoma. Eight days later, the patient has severe gross hematuria with clots requiring a return to the OR where the urologist performs a cystogram and fulguration of a bleeding vessel within the bladder at the ureteroneocystotomy, ureteral reimplantation site.

For the second surgery, report 52214-78 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands). Because your urologist had to perform the second surgery due to a complication resulting from the first surgery, you need to append modifier 78 to indicate that your physician performed surgery in the operating room to correct a complication from a prior procedure.

Next, report 51600-78 (Injection procedure for cystography or voiding urethrocystography) for the cystogram. If the patient's medical record shows documentation that the physician not only performed the cystogram and but also interpreted the results, you should also report 74430 (Cystography, minimum of three views, radiological supervision and interpretation).

Append modifier 26 (Professional component) to 74430 to indicate that you are only billing for the professional component -- the cystogram's interpretation.

Good practice: If the medical record does not clearly indicate the reason for the subsequent surgery, you should check with your urologist prior to selecting a modifier.