Article

Coding & Reimbursement

Modifier 58 in action

In ophthalmology, we use a number of common modifiers. One of the less common is number 58.

But, since “less common” does happen, here’s a review.

Q. What is modifier 58?

A. CPT defines modifier 58 as “Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period.” … “It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure.”

Q. How is modifier 58 different from modifier 78?

A. Place of service is a key discriminator between these modifiers. CPT defines modifier 78 as “Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period.”

Modifier 58 does not impose a place of service requirement.

Q. What is the effect of these modifiers on payment?

A. Modifier 78 causes reimbursement to be reduced; only the intraoperative portion of the procedure is paid because the postoperative period runs concurrent with that of the original procedure. Modifier 58 does not change reimbursement, and the postoperative period restarts for the second procedure.

Let’s look at some examples:

EXAMPLE 1: Planned intravitreal injections following vitrectomy

A patient undergoes a vitrectomy with internal limiting membrane peeling (CPT 67042) to treat residual diabetic macular edema. The operative report states that intravitreal injections of an anti-VEGF agent are planned. The injections would be part of postoperative care and not billable unless pre-planned. Modifier 58 applies for a planned procedure done in office.

EXAMPLE 2: Incomplete removal of a malignant skin lesion requiring a larger excision and repair

A surgeon removed a malignant skin lesion from the eyelid (CPT 11640). The pathologist’s report indicated that the margins were not clear — some cancer remains. One week later (within the global period), an excision and repair is performed (CPT 67966) to remove all of the remaining neoplasm and fix the defect. Modifier 58 applies for a related, more extensive procedure.

EXAMPLE 3: Injection of 5-FU following trabeculectomy

At the conclusion of a trabeculectomy (CPT 66170), the surgeon’s operative report indicates that 5-FU injections within the bleb are planned to control scarring. One week later (within the global period), the first subconjunctival injection (CPT 68200) of 5-FU is performed in the office. Modifier 58 applies for a related, planned procedure done in office.

EXAMPLE 4: Repair wound dehiscence following blepharoplasty

Three days after a blepharoplasty procedure (within the global period), the patient returns with an open wound from rubbing her eye. Two broken sutures are noted on exam. The surgeon cleans and re-sutures the lid in the office. Modifier 58 does not apply because the repair was not planned; it is part of the postoperative care for a complication.

EXAMPLE 5: Placement of amniotic membrane tissue (AMT) following corneal transplant and band chelation

This patient had a corneal transplant and bland chelation and presents for a one-week postoperative visit. At that time, the physician indicated she may need an AMT placed at the next visit in nine days. At that second visit, AMT was placed. Modifier 58 does not apply because the AMT is being used for a complication of the original surgery, and its use was not preplanned prior to the surgery.

EXAMPLE 6: Injection of triamcinolone acetonide for CME after cataract surgery

One week after cataract surgery with implantation of an IOL by your partner, the patient complains of poor vision. SCODI-P identifies CME. An intravitreal injection (CPT 67028) of triamcinolone acetonide is performed in office on the same day. Modifier 58 does not apply because the injection was not planned; it is part of the postoperative care for a complication. Only the test and the medication are reimbursed. OM