Importance of CPT Modifier 58 in Medical Billing

by | Published on Mar 23, 2022 | Medical Billing

Importance of CPT Modifier 58 in Medical Billing
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Modifiers are an important element in medical billing. A modifier offers physicians a way to report or indicate that a service or procedure has been performed and altered by some specific circumstance but not changed in definition. A modifier also provides additional information about the medical procedure, service, or supply in question without altering the meaning of the code. Carriers have specific rules on modifiers. Missing or incorrectly used modifiers can result in denied or rejected claims. Medical billing outsourcing to an expert can ensure the accurate use of modifiers to meet payer requirements.

There are many CPT modifiers and practitioners may be confused when it comes to choosing the right option for billing purposes. Here, we are going to discuss when modifier 58 should be used in medical billing and coding.

When to Submit Modifier 58

 The definition of Modifier 58 is: Staged or related procedure or service by the same physician during the postoperative period.
From the definition, it is clear that this is a surgical-specific modifier. CPT modifier 58 should be reported when a procedure or service performed during the postoperative period meets one of the following conditions:

  • Is planned or anticipated at the time of the original procedure (staged)
  • Is more extensive than the original procedure, or
  • Is for the therapy following a surgical procedure

Let’s look at three scenarios where the use of modifier 58 would be appropriate.

Example 1:  Revenue Cycle Advisor provides the following example (for professional fee billing) of a staged or planned procedure:

“A patient with diabetes and advanced circulatory problems came in for a surgical procedure to have a gangrenous toe removed from her left foot. On the day of the procedure, the physician let the patient know that her condition was progressing and that she may need to have her left foot amputated. A couple of weeks later, the physician performed an amputation of the patient’s left foot”.

Here, the second procedure was planned prospectively. A podiatry medical billing and coding company will report these services using the following codes and modifier 58:

  • 28820, amputation, toe; metatarsophalangeal joint
  • 28805-58, amputation, foot; transmetatarsal

 Example 2: The following example provided by Palmetto GBA is of a procedure that is more extensive than the original procedure:

“A right breast lesion removal (CPT code 19125) is performed on May 1 and was positive for cancer. On May 8, (within the global period of the previous surgery), a modified radical mastectomy including axillary lymph nodes, with or without pectoralis minor muscle (CPT code 19307) was performed”.

Since the mastectomy procedure was a more extensive procedure than the lesion removal, it should be reported with modifier 58 and the following code:

  • 19307-58

Example 3: Here’s another example from MedPro Disposal:

A surgical procedure is performed to debride a sacral ulcer. During the procedure, the surgeon knows a skin graft has to be performed on the ulcer site at a later date. As the surgeon anticipated the need for the skin graft at the time of the original procedure, the grafting must be billed with modifier 58.

When Submitting Modifier 58 is not Appropriate

Do not submit modifier 58 for the following:

  • E/M – Evaluation and Management
  • If the second procedure is unrelated
  • If the second procedure is performed by a surgeon of a different speciality/different provider group
  • For assistant surgery services (global surgery rules do not apply to assistants)
  • If the procedure is not performed in the post-operative period
  • If the procedure was not staged/planned at the time of the first procedure

There is often some confusion about Modifiers 58 78, and 79.  Though they apply to certain procedures that are performed within the “global period” of another procedure, and are very similar in definition, these three CPT modifiers are distinct in their scope and usage.

  • Modifier 58 applies to a “more extensive” procedure or staged procedure or service performed in the post-surgical period by the same physician.
  • Modifier 78 applies when an unplanned return to the operating room/procedure room occurs due to complications following the original surgery.
  • Modifier 79 is appended to report an unrelated procedure or service is performed by the same physician during the postoperative period.

Importance of Clear Documentation

Proper use of modifiers can help ensure accurate reimbursement for procedures performed. Clear, authoritative medical record documentation is essential to convey to the payers as to why modifier 58 was appended, and help prevent questions or delayed payment from payers. As a matter of fact, this applies to all CPT modifiers. Documentation must show that the two services were separate and distinct and support everything done by the physician. Clear documentation is also essential to understand when a modifier is needed. Skilled coders in a medical billing and coding company will be knowledgeable about payers’ specific rules with regard to the use of modifiers.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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