Catherine Posted Mon 07th of October, 2013 15:24:35 PM
Septoplasty '30520', submucosal ablation and turbinate reduction '30802, endoscopic-assisted left maxillary antrostomy with tissue removal '31267'. Patient return to office two days post-op '99024' and Dr performs nasal endoscopy for removal of mucus, crusting, and sutures. He codes '31231' and a '58' modifier. Patient is Medicaid only, which denies the procedure done on the post-operative visit, stating incorrect modifier. What is the correct modifier? '31231' is related to surgery.
SuperCoder Answered Tue 08th of October, 2013 08:22:44 AM
Coders often have a difficult time discerning when to use a 58 modifier versus a 78 modifier. One quick and easy way to differentiate is to ask yourself why the physician is doing the additional procedure in the global period. If it is because of the original condition which created the global period, then there is a good chance that the appropriate modifier is going to be the 58 modifier. However, if the reason for the new procedure is because of a prior procedure and not the original condition, i.e., a complication of the original procedure such as a post-operative wound infection or a post-operative hemorrhage, the 78 modifier may be more appropriate. Here is a little more detail:
Modifier 58. The modifier 58 is defined by CPT as “staged or related procedure or service by the same physician during the post-operative period.” It may be necessary to indicate that the performance of a procedure or service during the post-operative period was a) planned or anticipated (staged); b) more extensive than the original procedure; or c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure.
This modifier has multiple uses. Some people think that the physician has to specifically state planned stages in order for a procedure to qualify for the 58 modifier. This is not the case. The subsequent procedure can be within a stated plan of care, or it can be implied, executing a more extensive procedure because the original procedure did not achieve the desired outcome as planned.
1) Is the original condition is being treated?
2) Is the subsequent procedure more extensive than the first because the desired outcome was not accomplished?
3) Is something being done to “finish” what was started with the prior procedure?
4) Is a procedure being done to facilitate therapy, or is it therapy following a prior procedure?
Answering yes to any of these questions will direct you to the 58 modifier.
Modifier 78. Modifier 78 is defined by CPT as “unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the post-operative period. When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure.” This is providing care as an outgrowth of the original surgery, not the original condition.
Modifier 78 has two caveats attached to it:
1) The patient must be returned to the O.R. or endoscopy suite to qualify for the 78 modifier. Unlike modifiers 58 and 79, 78 may not be performed anywhere but in the O.R. or the endoscopy suite.
2) The reason for the subsequent surgery is related to the original surgery, meaning that there is a complication of the surgery requiring a return to the O.R. or endoscopy suite.