Some surgical care doesn’t end in a single operation, and the patient needs additional surgery in the postoperative period. Complex cases may be staged. Other cases may require an unexpected return to the operating room, or the patient may have bilateral disease. Here, I’ll explore the correct documentation and coding for these situations.
Modifier 58 is an important tool to allow a surgeon to bill for procedures when the patient requires a subsequent procedure following surgery. The definition of modifier 58 is:
Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period. 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.1
Some relatively common examples of when to use the 58 modifier include:
- preoperatively planned intravitreal
anti-VEG-F injections after a pars plana vitrectomy for diabetic retinopathy (staged);
- preoperatively planned silicone oil removal after retinal detachment surgery with silicone oil (staged); and
- laser retinopexy for retinal hole followed by unanticipated retinal detachment and return to the operating room for vitrectomy and retinal detachment repair (more extensive than original procedure).
The term staged implies preoperative planning; the preoperative note for the first procedure should indicate the intention to perform a second procedure.
Modifier 58 can be used for procedures performed in the clinic or in the operating room. Payment for the second procedure isn’t reduced; the postoperative clock restarts with the second procedure.
Unplanned return to OR
Modifier 78 is defined as, “Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period.”2 The first thing you may notice is “return to the operating room.” This is an important difference from modifier 58. Also, there is no preplanning or requirement that the second procedure be “more extensive.”
Modifier 78 examples include:
- after epiretinal membrane peel, a return to the OR for vitrectomy for persistent vitreous hemorrhage; and
- after complex retinal detachment repair, a return to the operating room for vitrectomy and intravitreal antibiotics.
Note that an “operating/procedure room” does not include a physician’s clinic-based procedure room. The Medicare Claims Processing Manual details what constitutes an OR: “An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures.”3 A dedicated laser suite may qualify as a procedure room.
Also note that if the second procedure is more extensive than the first, modifier 58 would apply. Modifier 78 reduces reimbursement and the postoperative clock is not reset; the postop period is calculated from the first procedure.
An unrelated procedure
Modifier 79 is significantly easier to understand than 58 and 78: “An unrelated procedure or service by the same physician or other qualified health- care professional during the postoperative period.”4
Unrelated procedures may include:
- panretinal photocoagulation on one eye with PRP on the fellow eye within the global period of the first procedure;
- epiretinal membrane peel during a cataract postoperative period; and
- intravitreal anti-VEGF injection in the postoperative period of a vitrectomy on the fellow eye.
Note that the place of service isn’t specified; an operating room or clinic service is allowed. The reimbursement for the second procedure is at 100 percent, and the postop periods for the first and second procedure run concurrently.
Documenting the preoperative plan accurately is important. The rationale for using 58, 78 or 79 hinges on the preoperative note. Having a full understanding of these important modifiers will allow you to submit accurate claims and assure appropriate documentation to support a second surgery in the global period. RS
1. Centers for Medicare and Medicaid Services. Staged or related procedures (Chapter 12§40.2 (A)(6)). Medicare Claims Processing Manual. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Updated July 25, 2019. Accessed November 6, 2019.
2. Centers for Medicare and Medicaid Services. Return trips to the operating room during the postoperative period (Chapter 12§40.2 (A)(5)). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Updated July 25, 2019. Accessed November 6, 2019.
3. Centers for Medicare and Medicaid Service. Definition of a global surgical package (Chapter 12§40.1 (B)). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Updated July 25, 2019. Accessed November 6, 2019.
4. Centers for Medicare and Medicaid Services. Unrelated procedures or visits during the postoperative period. (Chapter 12§40.2 (A)(7)). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Updated July 25, 2019. Accessed November 6, 2019.