Modifier 58 or 78? Master These Confusing Modifiers

choosing between modifier 58 and modifier 78 for procedures

Knowing when to use modifiers 58 and 78 isn’t easy. Base your choices on this straight-from-Medicare guidance to help ensure cleaner claims.

Make Modifier 58 Your Choice for Anticipated Procedures

Modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) is the focus of Medicare Claims Processing Manual (MCPM), chapter 12, section 40.2.A.6.

Here are the reasons that the MCPM gives for why a physician may use modifier 58 for a procedure during the postoperative period of another procedure:

  • The mod 58 procedure was planned prospectively or at the time of the original procedure
  • The mod 58 procedure was more extensive than the original procedure
  • The mod 58 procedure was for therapy after a diagnostic procedure.

A new postoperative period begins when you report modifier 58, the MCPM states.

Tip: Check your payers for modifier fact sheets and similar resources to help you understand the specific rules for the modifier. For instance, the WPS site states that appending modifier 58 to a code defined in CPT® as multiple sessions would be inappropriate usage. An example WPS gives is that you should not append 58 to “1 or more sessions” code 67208 (Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions …). A code like that is already priced by payers to included multiple sessions.

Use Modifier 78 for the Unexpected

In MCPM, chapter 12, section 40.2.A.5, you’ll find information about modifier 78 (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).

You can see that the modifier 78 descriptor specifies “unplanned” in contrast to the term “staged” used in the modifier 58 descriptor.

You should append modifier 78 to the appropriate code when you report treatment that requires a trip to the OR for a complication or unanticipated problem (related to the first procedure), the MCPM states.

Tip: Again, modifier fact sheets and similar resources can be your friend. For instance, on the Palmetto site, you’ll find this instruction, which you’ll find on other Medicare sites, too: “An operating room for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room or an intensive care unit.” The Palmetto site adds this: “unless the patient’s condition was so critical there would be insufficient time for transportation to an operating room.”

Example: The Palmetto site offers the example of a patient having a colon resection (44143) with a return to the OR to control bleeding (49002-78) on the same date. Note the use of modifier 78 on the code for the service that required a return to the OR.

What About You?

How do you decide when you use modifiers 58 and 78?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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