Health Information Management

Tip: Use modifier -58 for planned return to the OR

APCs Weekly Monitor, December 11, 2009

Want to receive articles like this one in your inbox? Subscribe to APCs Weekly Monitor!

Physicians sometimes decide to perform surgery in stages. These situations involve a planned return to the OR. Append modifier -58 (staged or related procedure or service by the same physician during the postoperative period) to:
 
  • Staged procedures planned prospectively at the time of initial surgery
  • Subsequent surgery that is more extensive than the original procedure
  • Therapeutic surgery following a diagnostic surgical procedure
 
For example, if a physician leaves an incision and drainage open and plans fracture debridements, append modifier -58 to the additional debridements.
 
Don’t append modifier -58 if the patient’s return to the OR is unplanned. For example, a surgeon removes polyps from a patient’s colon. Several hours later, the physician returns the patient to the OR and performs a colonoscopy with electrocautery to control postoperative bleeding. In this situation, append modifier -78 (return to the OR for related procedure during the postoperative period [same day]).
 
This tip was adapted from the article “Master modifiers to ensure accurate reimbursement” in the December issue of Briefings on APCs.



Want to receive articles like this one in your inbox? Subscribe to APCs Weekly Monitor!

Most Popular

Related Articles