Modifier 58 appends with the service when the same Physician performs a Staged or Related Procedure or Service during the postoperative period.
Modifier 58 Description
Modifier 58 applies for services performed second, staged, or subsequent service or procedure during the postoperative period by the same Physician.
Modifier 58 may apply with the service, such as surgical services that require more than one session or may require physical therapy service after the surgical procedure. Global modifiers (58, 79, 78) may need additional operations performed by the same Physician during the postoperative period.
For treatment of a problem that requires returning to the operating/procedure room (e.g., unanticipated clinical condition), see modifier 78.
Modifier 58 is inapplicable to use with the claims on when assistant who assists the procedure or service during the postoperative period. It is appropriate to report these services with modifier AS 80, 81, or 82 in addition, and 58 may “returned as non-processable” with remark code MA130. It may require eliminating modifier 58 from the claim and need resubmission.
What Is Modifier 58?
Modifier 58 indicates the service when the Physician performs more extensive procedures than the same Physician’s original or subsequent related procedure during the postoperative period. It will start a new postoperative period when completed.
When To Use Modifier 58
The following are an appropriate use of modifier 58:
Modifier 58 appends with service when the Physician performs the service or procedure during the postoperative period, which is planned by the Physician at the time of the original service more routinely.
Modifier 58 appends with service when the Physician performs a more extensive procedure than the original one.
58 appends with service when the Physician performs therapy services as the result of diagnostic services or procedures.
Modifier 58 appends with service when the same Physician performs a related or second procedure in the postoperative period.
Modifier 58 Guidelines
The following are the guidelines when modifier 58 appends with CPT codes:
Documentation must support the use of 58 on the claim that the service performs medically necessary and appropriate for patient conditions. The summary report and circumstance may submit to the insurance if required.
Modifier 58 does not apply to evaluation and management services (99201-99499). It is appropriate to report with modifiers 24, 25, 57, etc. For Instance, the Physician provides the service on the day of surgery or before that day when they decide to perform the procedure, which has 90 days global period. It is appropriate to report this service modifier 57 instead of 58.
Modifier 58 is inappropriate to bill with an assistant when performing the service or surgery procedure under the Physician’s supervision.
58 is inappropriate for bills with ambulatory surgical center (ASC) facility fee claims.
Modifier 58 only applies when the subsequent or second procedure performs in the postoperative period, not the original service with a 10 or 90 days global period. For Instance, The patient sees the patient and operates the formation of a pedicle flap on the cheek-to-nose skin flap. CPT code 15576 may report for this service to maintain the blood supply. The second procedure performs after two weeks to permanently fix the nose (CPT code 15630). It is appropriate to report this procedure 15630 with modifier 58.
It is inappropriate to report modifier 58 with an unrelated procedure or service in the postoperative period by the same Physician, and it may bill with modifier 79.
Modifier 58 is inappropriate to report with the service or procedure when performed in return to the operating room due to the complication of original service, or may service does not require a return to the operating room.
Modifier 58 does not include applicable with the following CPT codes 65855, 66762, 67101, 67105, 67141, 67145, 67208, 67210, 67218, 67227, and 67228:
It is inappropriate to report modifier 58 with these CPT codes because the code descriptor contains “one or more sessions.” It means that this service may require additional or subsequent sessions later. It is inappropriate to add 58 with these procedure codes.
The Physician performs defined treatment depending upon the presenting patient’s problem, diagnosis, and treatment location. CMS Medicare considers these services as the defined global surgery period. These CPT codes may report once because it includes all the session in the global period.
For Instance, The Physician performs the procedure on the shoulder region, while previous surgery on the pelvic area has 90 days global period. It is suitable to report this procedure with modifier 79 instead of 58. If the patient sees by the Physician during the postoperative period with an unrelated or related different condition, it is appropriate to report with modifiers 78 and 79.
CPT 67228 may report once, including surgery, appropriate follow-up, and postoperative management over the ensuing global surgery period.
Modifier 58 Examples
The following are the examples of modifier 58 when appended with the CPT code:
A 52-year-old male presents to the Physician’s office with diabetes with advanced circulatory problems. The patient had gangrene on his left foot, and the Physician removed the gangrene toe from the body on March X, XXXX.
The Physician has planned at the time of surgery that the patient may have to remove the complete foot later. The patient returned to the Physician on April XX, XXXX, and needed amputation of the remaining left foot.
The Physician performs the second procedure (March XX, XXXX), which reports with CPT code 28805 and modifier 58 required to indicate the staged service. CPT 28820 is appropriate to bill the operation of April XX, XXXX, which has 90 days global period. Otherwise, it may deny by the insurance.
A 35-year-old female without prior medical history presented to the emergency department with c/o constant midsternal chest pain two days ago, intermittent chest pain today, pressure-like sensation with intermittent shortness of breath. The patient denies any pain currently.
The patient thought it was related to the digestive system and took some medication for digestion. Denies trauma, heavy lifting, palpitations, dizziness, cough, recent illness, fever, chills, back pain, abdominal pain, nausea, recent travel, known sick contacts, current antibiotic use, near-syncope, or syncope, changes in stool color, urinary complaints, or any other symptoms.
The patient did not take any medication for pain. The patient vapes and drinks alcohol on occasion and denies illicit drug use. The Physician ordered a CT scan of the chest, cardiac profile, and Laboratory studies.
CT chest reveals that the patient had a cancerous lesion on the right breast, which is the leading cause of the patient’s condition. The Physician performs the removal of the right breast lesion, and pathologies study positive for cancer.
The Physician plans the subsequent procedure to remove the mastectomy, which may report with a modifier because it is a more extensive procedure.
A 39-year male presents to the office with the BPH benign prostatic hyperplasia and a family history of prostate cancer. He has a problem with urination, feels itching and pain, and does not take any medication for these problems.
The patient denies swelling in the upper and lower extremity regions, recent travel, UTI, and headache. The physical examination reveals a bump in the male genital area.
The physician orders an MRI of the prostate, which reveals a lesion in the prostate region. The Physician performs an incisional biopsy of the prostate to determine whether it is malignant or benign and shows cancer,
CPT code 55705 may report for the first procedure and subsequent service performed two weeks later when the patient returns for radical therapy for prostate cancer. It is appropriate to bill this service with modifier 58.
If a diagnostic endoscopic procedure results in the decision to perform an open procedure, both procedures may be reported with modifier 58 appended to the HCPCS/CPT code for the open procedure.
However, if the endoscopic procedure preceding an open procedure is a “scout” procedure to assess anatomic landmarks and/or extent of disease, it is not separately reportable.
Another example of when to use the 58 modifier would be if a patient had a removal of a breast lesion (CPT 19120) followed in less than 90 days by the removal of the entire breast (CPT 19307).
Bill CPT 19307-58 for the second procedure. Another postoperative period begins when the second procedure in the series is billed.
Modifier 58 vs 78
Modifiers 58 and 78 bill for the same Physician’s services performed during the postoperative period. The following are differences between modifiers 58 and 78:
Modifier 58 influences the global period and begins a new global period when service performs in the postoperative period. Unlike modifier 78, 58 is a planned or stage procedure performed in the postoperative period by the same Physician.
It does not require a patient to return to the operating room due to complications. It may result in full payment of the claim, and the procedure or service may be more extensive than the initial procedure.
Unlike 58, Modifier 78 is an unplanned return to the operating room and service performed by the same Physician throughout the postoperative period. It may perform by the Physician in return for complications.
It may lead to the lower reimbursement of the claim based on the CMS fee schedule. In contrast, Modifier 78 does not affect the global period and will remain effective as the original procedure.
For Instance, the Physician performs a biopsy to identify whether the mass is cancerous or not, which may result in cancer. They perform the subsequent procedure to remove cancer. It is appropriate to report with 58.
In contrast, a female had caesarian delivery a week ago and returned to the operating room for heavy bleeding, and it is appropriate to report with modifier 78.
Inappropriate Usage of Modifier 58
Modifier 58 needs to be reported correctly. The following situations are inappropriate.
Appending the modifier to ASC facility fee claims
Appending the modifier to a procedure with a global period on the MPFSDB
Appending the modifier to services listed in CPT as multiple sessions, (i.e. 67208, Destruction of localized lesion of retina, one or more sessions)
Reporting the treatment of a complication from the original surgery
Unrelated procedures during the postoperative period
Do not use this modifier to report the treatment of a problem that requires a return to the operating room (see Modifier 78).
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.
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.