Health Information Management

Tip: Differentiate between modifiers -58 and -78

APCs Insider, October 29, 2010

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Coders may struggle to determine when to use modifier -58 (staged or related procedure or service by the same physician during the postoperative period) or modifier -78 (return to the OR for related procedure during the postoperative period [same day]).

In some situations, a physician may plan or stage second procedures for a patient that falls within the original procedure’s global period. For example, a physician performs a debridement of a patient’s burn. The physician knows he or she will need to perform additional debridements and documents this in the patient’s chart. When the physician performs the additional debridement, append modifier -58.

The physician may also need to perform a more extensive procedure than the original one. For example, a physician performs a breast biopsy and diagnoses the patient with breast cancer. One week later, the same physician performs a modified radical mastectomy on the right breast. In this case, append modifier -58 to the code for the modified radical mastectomy.

Append modifier -58 for the following:

  • Procedures that are planned or anticipated (staged)
  • Therapy following a surgical procedure
  • Procedures that are more extensive than the original procedure

You can use modifier -58 even when the physician did not plan the staged or related procedure, if it is more extensive than the original procedure.

Do not use modifier -58 if the physician returns the patient to the OR because of unplanned complications to a procedure. 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 case, append modifier -78.

This tip was adapted from “Messy modifiers: -25, -52, -58, -78, and -59 explained” in the October issue of Briefings on APCs.



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