Modifier 58 | Staged or Related Procedure During Postoperative Period

Modifier 58 describes a staged or related procedure or service by the same physician or another qualified healthcare professional during the postoperative period.

1. What is modifier 58?

Modifier 58 is a CPT® modifier used to indicate that a provider performed a new and subsequent procedure during the postoperative period.

This modifier is used when a provider performs a planned or staged procedure after an initial procedure for different reasons, such as allowing a patient time to heal from the first surgery or for an infection to resolve.

The new procedure typically has its global period, separate from the first procedure.

2. When to use modifier 58?

Modifier 58 should be used when a provider performs a planned or staged procedure during the postoperative period.

This includes procedures that are more extensive than the original procedure, therapy following a surgical procedure, and the reapplication of a cast within a 90-day global period.

Examples of when to use modifier 58 include multiple procedures for skin grafting or scar revision, weight loss surgery requiring staged procedures, procedures that providers typically perform in two stages, removal of excess skin after weight loss, and procedures to treat pressure ulcers.

3. Description

The official description of modifier 58 is a “staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period”.

4. Examples

Examples of procedures that require modifier 58 include:

• Multiple procedures for skin grafting or scar revision, when the provider performs each procedure at a different stage of healing
• Weight loss surgery requiring staged procedures
• Procedures that providers typically perform in two stages
• Removal of excess skin after weight loss, requiring the provider to wait a specific number of days between each staged procedure
• Procedures to treat pressure ulcers requiring an initial procedure for debridement and subsequent procedures for reconstruction

5. Documentation

When using modifier 58, the provider needs to document each stage of the surgery and plans to return the patient to the operating room for additional procedures to manage the patient’s condition. This modifier only applies to procedures with postoperative periods.

When the provider treats an unanticipated condition that requires a return to the operating or procedure room, append modifier 78 to the procedure, not modifier 58.

6. Billing

To bill for a procedure using modifier 58, the provider should append the modifier to the CPT® code for the subsequent procedure.

The provider should also ensure that the documentation supports the use of the modifier and that the procedure is not included in the global period of the initial procedure.

7. Common mistakes

Common mistakes that medical coders make when using modifier 58 include using it for procedures that are not planned or staged, using it for procedures that are included in the global period of the initial procedure, and failing to document each stage of the surgery and plans for returning the patient to the operating room for additional procedures to manage the patient’s condition.

To avoid these mistakes, medical coders should ensure that the documentation supports the use of the modifier and that the procedure is not included in the global period of the initial procedure.

8. Other modifiers related to modifier 58

Other modifiers related to modifier 58 include modifier 78, used when the provider treats an unpredictable condition that requires a return to the operating or procedure room, and modifier 79, used when the provider performs a procedure unrelated to the original procedure during the postoperative period.