Modifier 58 vs 78: Boost Pay-up for Post-Op Procedures

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Modifier 58 vs 78: Boost Pay-up for Post-Op Procedures

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Modifier 58

Using modifier 58 to code post-operative procedures can prevent payer denials and decreased reimbursement for services – but you must use it correctly.

When coding post-op procedures, most problems occur because of the similarities between two key modifiers:

  • Modifier 58 – staged or related procedure or service by the same physician during the postoperative period,
    and is more extensive than the initial procedure.
  • Modifier 78 – Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postoperative period.

Although the definitions of modifier 58 and 78 have parallels, there are key differences related to when you should apply each code.  You must master the difference, or you could end up providing these post-op services for free. Incorrect usage of modifiers 58 and 78 can lead to increased denied claims, overpayment for services, audits, and even violation penalties.

Modifier 58 Dos and Don’ts

The definition above for modifier 58 makes its application seem pretty straightforward.  It clearly states that the modifier should be used when your provider performs staged or related services during the global post-operative period.  However, coding correctly is rarely this simple, and this is no exception.

There are several other situations you should consider beyond the straight definition before applying modifier 58 to the related procedure code on your claim:

  • The doctor expects the surgical procedure to take more than one session to complete
  • The subsequent procedure is more extensive than the original surgery, either as part of the process or because the first procedure didn’t produce the desired outcome
  • For therapy following a surgery.

Note: This modifier should NOT be used to code procedures that relate to the treatment of unplanned complications that arise during or as the result of a surgery. Instead, modifier 78 would be more accurate.

58 vs. 78 Simplified

When you apply modifier 58 to a procedure, it re-starts the global period and results in full payment for each procedure. On the flip side, modifier 78 does not break the original global period and will result in a reduction in payment based on each individual payer’s fee schedules.

To help you utilize these modifiers correctly, try answering these two questions before you code your post-op claims:

    1. Are you treating the patient’s original condition more extensively, in stages, or providing therapy?
    2. Are you treating a complication of the initial surgery?

If your answer to question 1 is “Yes” then you would use modifier 58 applied to the related procedure code.  For question 2, a “Yes” answer means that you would apply modifier 78.

In addition to the questions above, use the post-op examples below to help you more accurately apply both modifiers 58 and 78 to your post-op surgery claims.

Modifier 58 Post-Op Examples

When determining whether to utilize modifier 58, your provider’s documentation should clearly indicate that the  additional procedure or follow-up therapy is indicated as a result of the patient’s initial surgery, and whether it will be performed within the global period of the original surgery.

Here are some case examples where modifier 58 is indicated:

  • A 65-year-old male patient has a malignant skin lesion removed during an office visit. This procedure includes a 10-day post-op global period. Your surgeon indicates in the patient file that he plans to close the patient’s excision on the 9th post-op day.The post-op procedure in this case is clearly related to the original surgery (it is a subsequent procedure to the original). Also, the surgeon documents that he is planning to close the lesion before the end of the 10-day global period ends.
  • A 68-year-old female patient undergoes a biopsy on her right breast and receives a diagnosis of breast cancer. A week later, the physician performs a modified radical right breast mastectomy.

In this case, the initial biopsy should be considered the primary procedure, the more extensive mastectomy procedure is due to the results of the biopsy, and the mastectomy is being performed within the global period.

It’s important to note that, although modifier 58 is most often used for planned follow-up procedures, it can be used for unplanned subsequent procedures as well. This is true even if the follow-up procedure is more extensive than the initial one.  As long as the follow-up procedure is an extension of or an addition to the initial procedure, modifier 58 should be applied.

Modifier 78 Tip:
In cases where a second surgical procedure is required to deal with complications arising from the initial surgery, such as an infection that develops in an incision site, modifier 78 should be applied instead.

Coding surgical procedures and everything that goes with them can be complicated. Don’t risk using the incorrect modifier and facing down decreased payment or claims denials. For practical, step-by-step guidance when using surgical modifiers, check out this immediately available training, Boost Surgical Modifier Pay-up and Avoid Audit Penalties, presented by expert, Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO. This 60-minute training gives you the help you need to correctly code your surgical claims every time to avoid missing out on the reimbursement you are due. Access this training today.

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