Avoid the Top 10 Modifier Mistakes – Modifier 58

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Avoid the Top 10 Modifier Mistakes Modifier 58

• Matching CPT code with an ICD 10 code, this would
  seem to be a very straightforward process but
  there are always variations/exceptions to
  everything. Sometimes, there are related services
  that the physician is performing, global periods
  to contend with, etc. Modifiers will clarify
  extenuating circumstances, which should allow for
  payment when they otherwise may not. That said,
  the improper use of modifiers can be the cause of
  claim denials just as not using a modifier can
  be. When using modifiers, make sure you clearly
  understand what the modifier entails.
• In this, and the following blogs, we identify 10
  of the most commonly misused modifiers to help
  you become more aware of the issues surrounding
  them. Well help you understand why they are
  problematic and how you can use them correctly.
• Modifier 58
• Modifier 58 Staged or related procedure or
  service by the same physician during the
  postoperative period may be necessary to indicate
  the performance of a procedure during the
  postoperative period was
• Planned prospectively at the time of the original
  procedure, or staged
• More extensive than (that is, goes beyond) the
  original procedure or
• Therapy following a diagnostic surgical
  procedure.

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Avoid the Top 10 Modifier Mistakes Modifier 58

• When reporting Modifier 58, the physician may
  need to indicate that the procedure or service
  was
• Planned prospectively at the time of the original
  procedure, or staged.
• More extensive than the original planned
  procedure.
• For therapy following a diagnostic surgical
  procedure.
• Do not use this modifier to report the treatment
  of a problem that requires a return to the
  operating room.
• The existence of CPT Modifier 58 does not negate
  the global fee concept therefore, services that
  are included in CPT as multiple sessions or are
  otherwise defined as including multiple services
  or events may not be billed with this modifier.
• Modifier 58 should not alter the amount charged
  or paid for subsequent unrelated or staged
  procedures that are performed during the
  postoperative period of a previous procedure.
  Modifier -78 may drive a reduction because it is
  for management of a complication resulting from
  the previous procedure.
• Example 1 A patient has a malignant melanoma
  removed from his shoulder and the physician takes
  a lymph node biopsy (38510, Biopsy or excision of
  lymph nodes open, deep cervical node(s)).
  Pathology determines that the lymph node has
  metastatic malignancy, so the physician schedules
  the patient to come back for a lymph node
  dissection, which you would document with a code
  in the 38500-38555 (Biopsy or excision of lymph
  node(s) ) range,appending modifier 58 to the
  procedure code.

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Avoid the Top 10 Modifier Mistakes Modifier 58
Example 2 A procedure that is more extensive
than the original procedure On May 1, the
patient presents to the OR for the removal of a
right breast lesion. On May 3, the pathology
report returns and indicates the lesion is
malignant. On May 9, within the global period of
the initial surgery, the patient is returned to
the OR for a modified radical breast mastectomy
by the same surgeon. Appropriate coding is May
1 19120-RT Excision of the cyst, fibroadenoma,
or other benign or malignant tumor, aberrant
breast tissue, duct lesion, nipple or areolar
lesion (except 19300), open, male or female, 1 or
more lesions (90 global days). Modifier RT Right
side indicates location. The diagnosis is 239.3
Neoplasms of unspecified nature breast. May 9
19307-58-RT Mastectomy, modified radical,
including axillary lymph nodes, with or without
pectoralis minor muscle, but excluding pectoralis
major muscle with 174.1 Malignant neoplasm of the
female breast a central portion. The diagnoses
are different for each procedure. The subsequent
diagnosis discovery on May 3 resulted in the need
for a more extensive procedure.
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Avoid the Top 10 Modifier Mistakes Modifier 58

• Inappropriate Usage
• Appending the modifier to ASC facility fee claims
• Appending the modifier to a procedure with XXX
  global period on the MPFSDB
• Appending the modifier to services listed in CPT
  as multiple sessions, (i.e. 67208, Destruction of
  localized lesion of the retina, one or more
  sessions)
• Reporting the treatment of a complication from
  the original surgery
• Unrelated procedures during the postoperative
  period