Health Information Management

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

APCs Insider, December 11, 2009

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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.



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