What does it mean? When is it appropriate?

Understanding the definition and applicability of modifier 58 is a key to accurate coding during the global period. Its proper use will also reduce your risk of an audit during the global period.

Defining Modifier 58
Modifier 58—staged or related procedure or service by the same physician during the postoperative period—is used to report a surgical procedure that is staged or related to the primary surgical procedure and is performed during the global period. It is most commonly applied in the following instances:

• The second procedure is anticipated or planned to manage the underlying condition.
• A second, more extensive procedure is needed to treat the underlying disease process.
• A therapeutic procedure following a surgical procedure is planned.

Modifier 58 may be appended to surgical CPT codes in any place of service, assuming that the second or subsequent procedure is staged or anticipated, planned, or more extensive than the original procedure.

The global period restarts with the subsequent procedure, and the surgeon should receive 100 percent of the allowable reimbursement on both the first and the subsequent procedures.

Appropriate multiple procedure payment rules apply if multiple procedures are performed at the subsequent session.

Applying Modifier 58
The following clinical example shows how to apply modifier 58.

On Nov. 1, a patient who had been attacked by a mountain lion was brought to the emergency department (ED). The initial evaluation revealed a comminuted segmental fracture of the left fibula with no associated tibial fracture. The arterial assessment showed a weak popliteal arterial pulse, a palpable femoral arterial pulse, but no distal pulses were detected. A large soft-tissue defect was present. The patient was taken immediately to the operating room (OR).

The surgeon dictated the following in his operative note on Nov. 1:

• Exploration of posterior tibial vessels and peroneal vessels without repair
• Excisional débridement of skin, devitalized muscle, fibula bone fragments, and fat, and extensive débridement of the posterior wound toward the posterior popliteal fossa on the left.

The immediate goal was to assess the extent of this massive injury and to cleanse the wound of contaminated and devitalized tissues. The operative note indicates loss of motor and sensory function in the left foot and questionable viability for reconstruction. The surgeon dictated a planned second stage to further assess the injury and reconstructive options versus amputation.

Table 1 shows the reporting for this procedure, based on the documentation within the operative note details.

Two days later, the patient was returned to the OR for the planned second stage surgery. The surgeon began his operative note by saying, “We bring the patient back today for re-assessment of the wound and assessment of neurovascular status. Based on our findings, the leg was amputated and the wound not closed to reduce the risk of infection and to promote healing for possible closure at next session. We plan to manage the wound at the bedside with dressing changes and will return the patient to the OR for another excisional débridement if necessary.”

To summarize, the surgeon performed a below-the-knee amputation of the left lower extremity and planned for a subsequent delayed closure due to the nature of the wound. Table 2 shows the reporting for this second, staged procedure.

On Nov. 10, the patient was returned to the OR for the third procedure to treat an open below-knee amputation of the left lower extremity. According to the surgeon’s dictation, “We plan to do an exploration of the wound, irrigation and débridement, and secondary closure of tissue around the stump if possible. We found the tissue to be of good quality and adequate such that the muscle could cover the bone. No further bone débridement was required.”

Table 3 shows what the surgeon reported. Irrigation of the wound is included in the secondary closure. Any débridement that may have been necessary is also included.

Additional E&M coding
In the above situation, the patient was brought to the ED and was being managed by the general surgery trauma team. The trauma team requested an orthopaedic consultation. This evaluation and management (E&M) service (the decision for surgery) is separately reportable and requires modifiers to protect it from being bundled into the surgical package. Because the surgeon performed both a major and a minor procedure on the same day as the E&M service, the use of modifiers 57 (decision for surgery) and 25 (significant separate service on the same day as another service) was required. Both modifiers are required due to the different global periods and requirements to protect the E&M from bundling.

Key concepts
When dealing with modifier 58, remember the following key concepts:

• Dictate each stage of the surgery and your plans for returning the patient to the OR for additional procedures to manage the traumatic injury.
• Append modifier 58 to each CPT code in the second and third sessions to indicate prospectively planned returns to the OR to treat the complexity of the disease process if these subsequent procedures are within the global period of the first procedure.
• Report each procedure in full and expect 100 percent reimbursement on each primary procedure at each stage. If, however, more than one procedure is performed during the first and subsequent operative sessions, expect the payor to apply a multiple procedure payment formula to them.
• Monitor accounts receivable to ensure proper payment on each stage.
• Review the global service data portion of Code X (GSD tab) to ensure that services not included in the intraoperative services are reported in addition to other procedures (i.e., 35761).
• Use Code X to find modifiers (Modifier tab); to ensure payments are correct, use the Fee Schedule Calculator found in the RVU tab under the Calculator tab.
• Use appropriate codes and modifiers for any additional E&M services (i.e., consultation).

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates. The information in this article has been reviewed for accuracy by AAOS Coding, Coverage, and Reimbursement Committee members M. Bradford Henley, MD, MBA, and Blair C. Filler, MD. If you have coding questions or would like to see a coding column on a specific topic, e-mail aaoscomm@aaos.org