Just as authors use various circumstances and experiences to provide context in their books, modifiers do the same in medical billing. They provide additional information about procedures or services performed by healthcare providers.
Modifiers are concise, two-digit codes that billing specialists pair with HCPCS or CPT codes. They can be alphabetic, numeric, or a combination of both and convey significant details, like which side of the body the procedure was performed on or whether it was pre-planned or spontaneous.
Many practices experience claim denials because coding staff often overlook modifiers, usually due to their vague descriptions. We don’t want you to face that! Let’s discuss one of the most important modifiers—Modifier 58.
What is Modifier 58?
Post-operative care has many follow-up services to manage a patient’s pain. Some procedures, like skin grafting after burn injuries, are necessary for recovery. Modifier 58 in medical billing is used to indicate such operations or services. In simple terms, this modifier specifies three things:
- The follow-up procedure was planned during the initial diagnostic surgical operation.
- It was more extensive than the original surgical intervention.
- It was necessary for a patient’s recovery.
Keep in mind that a new global period may begin after the subsequent procedure. However, modifier 58 only addresses those pre-planned services performed within the original surgical global period. Moreover, you should only use this modifier if the staged procedure is performed by the same physician who conducted the original surgery.
Also, remember that one of Medicare’s conditions for applying modifier 58 is that the patient must return to the operating room (OR) for the staged procedure unless their condition is so critical that there is no time to transport them.
Want to use this modifier correctly? Let’s look at some scenarios where modifier 58 is applicable.
Scenarios Where Modifier 58 is Applicable
The following examples highlight different situations where modifier 58 is applicable.
Example #1: Subsequent Tumor Removal Surgery After Biopsy
A patient undergoes an ovarian biopsy via a laparotomy (large incision in the abdomen) or laparoscopy (small cut in the lower abdomen). The results conclude that the sample is cancerous. A gynecologic oncologist then plans a more extensive procedure to remove all visible tumors within the patient’s abdomen and pelvis.
Billing specialists use modifier 58 when the surgeon performs this surgery within the biopsy’s global period (4 to 6 weeks).
Example #2: Breast Reconstruction after Mastectomy
A patient with breast cancer undergoes a breast reconstruction procedure after mastectomy. A board-certified surgeon performs this autologous tissue reconstruction – rebuilding the breast using a piece of tissue with skin from elsewhere in a woman’s body – within the global period of the main operation (90 days).
Since this reconstruction is performed in multiple stages, you can apply modifier 58 to each subsequent staged procedure, as they are all part of the overall staged operation.
Modifier 58 vs 78
Both modifiers 58 and 78 are used to address follow-up procedures during a patient’s global period. However, they are slightly different. Let’s break down these differences.
Purpose
Modifier 58 reports staged or planned procedures directly related to the main operation. On the other hand, modifier 78 addresses unplanned interventions typically performed to address post-surgery complications. This modifier also only addresses medical procedures within a patient’s post-operative care period.
In simple words, this modifier notifies payers that the second procedure was unexpected but necessary to address an issue that occurred due to the original surgery.
Global Period
Another key difference between these two modifiers is the global period. Modifier 58 resets the global period with a subsequent procedure, leading to a surgeon receiving full payment for both the original and the following procedure.
In contrast, modifier 78 does not restart the global period as it is used when a patient only returns to the operating room due to an unexpected post-surgical outcome. As a result, payers only offer complete payment for the primary surgical intervention but only partially cover the unplanned follow-up operation.
| Modifier | Subsequent Procedure | Global Period | Reimbursement |
|---|---|---|---|
| 58 | Planned | Resets | Complete reimbursement for both procedures |
| 78 | Unplanned | Remains the same | Only primary operation is fully covered |
Modifier 58 vs 79
Modifiers 58 and 79 have only one key difference. By now, you should be familiar with modifier 58. You can use it to bill follow-up services related to a primary operation. However, not every procedure is linked to the diagnostic surgery. So, what should you do in that case? You use modifier 79.
This two-digit code addresses new and unrelated procedures performed during the global period of the initial operation. To put it simply, you can use modifier 79 to request separate reimbursement for the second procedure. Both modifiers, however, address only those operations performed by the same physician who conducted the initial surgery.
| Modifier | Subsequent Procedure | Global Period | Reimbursement |
|---|---|---|---|
| 58 | Related to the main operation | Resets | Complete reimbursement for both procedures |
| 79 | Unrelated and new procedure | Resets | Complete reimbursement for both procedures |
Summary
To summarize, modifiers tell the story of a particular encounter in medical settings. They provide additional context to a performed service or procedure. The unique aspect of these two-digit codes is that they don’t change the description of the service but rather improve the understanding of the insurance payers.Therefore, insurance companies immediately reject claims without modifiers (if required). One of the most important modifiers in medical billing is modifier 58, which specifies that a follow-up procedure is staged and related to the main operation. Don’t make the same mistake as many other practices. Use this modifier appropriately to avoid payment issues.
