Wiki Modifier 58

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It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure.


Examples:

When to use modifier 58

Scenario 1
A patient with gangrene has his toe amputated. But on follow-up, it is determined the patient actually needs to have the rest of his foot removed because the original procedure didn't completely take care of the problem.
Coding
28805-58 if the second amputation occurs within the designated post-operative period of the first amputation
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Scenario 2
A pedicle flap is performed to reconstruct a soft tissue defect of a finger. Three weeks later a division and inset is performed.
Coding
Stage I: 15574 (flap); Stage II: 15620-58 (division and inset finger flap).
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Rationale
Modifier 58 is an extremely important for plastic surgeons. Many staged flap procedures as well as debridements and STSG's for major burns are performed during the "global" post-operative period of an initial procedure. If staged procedures are anticipated, this should be clearly stated in the operative note of the initial procedure. Also use modifier 58 if a lesser procedure must be performed (biopsy, for example) prior to a greater, definitive procedure.
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what about a follow up procedure in the office. I thought I had read somewhere that the surgeon would need to have documentation either in the op note or in the (office note before the surgery) stating the patient may have to return for scopes and or debridements during the post-op period.
 
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For ENT best example I can think of, is the 69801-58. Basically it's 3 injections and they are staged over a few weeks. Also we use laterality for the 69801. So either 69801-RT-58 or 69801-LT-58, and we bill for each visit as such.

In regards to cibcarey's question on the post-op period, very often -79 will be applicable for those procedures. In our experience, the scope or debridement is for a unique Dx that is not truly specific to the original procedure. Usually that's for sinus procedures; say a 31267-LT is done in OR, then post-op it's not unusual to do 31575-79 for laryngitis or 31231-79 or 31237-79; these are not often bundled with the OR sinus surgery.
 
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Actually, ENTcoderConnecicut, 69801 is now a zero global day procedure.

An example when Oto uses 58 is when a staged procedure is performed, eg: a resection of a lipoma (soft tissue tumor) of the cheek down to subcutaneous tissue, 3.5cm (21012) and then 30 days later, doing an adjacent tissue transfer to close the defect. The 14040 will be coded with a 58 modifier because it was a staged repair to the resection, 21012, the procedure performed 30 days ago, which had a 90 day global
 
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