In a retinal practice, we use a number of common modifiers. One of the less-common, however, is modifier 58. Here’s what you need to know about using this modifier.
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. 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 preplanned. Modifier 58 applies for a planned procedure done in office.
- EXAMPLE 2: Laser for a retinal tear followed by a retinal detachment (RD) repair. A patient is treated with laser for a retinal tear (CPT 67145). Two weeks later (within the global period), the patient returns with new signs and symptoms and is diagnosed with a retinal detachment related to the earlier tear. The surgeon performs an RD repair, starting with a pars plana vitrectomy, in the operating room. Modifier 58 applies for a related, more extensive procedure.
- EXAMPLE 3: Failure of initial RD repair requiring a more extensive re-repair. A surgeon performs a RD repair with vitrectomy (CPT 67108). Two months later (within the global period), the patient develops PVR and a tractional detachment in the same eye. Re-repair is performed but it is significantly more complex (CPT 67113). Modifier 58 applies for a related, more extensive procedure.
- EXAMPLE 4: Injection of triamcinolone acetonide for cystoid macular edema (CME) after cataract surgery. One week after cataract surgery with implantation of an IOL by your partner, the patient complains of poor vision. Scanning computerized ophthalmic diagnostic imaging of the posterior segment identifies CME. An intravitreal injection (CPT 67028) of triamcinolone acetonide is performed in the lane 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.
- EXAMPLE 5: Planned removal of silicone oil following vitrectomy. Silicone oil is injected in chronic retinal detachment, proliferative vitreoretinopathy, advanced diabetic retinopathy, macular holes, and other disease processes that require long-term retinal tamponade following vitrectomy. Once the eye is relatively stable, the surgeon removes the silicone oil to avoid long-term complications. Surgeons plan to remove the oil as the eye approaches stability, but ultimate stability is not achieved until the final staged procedure — removal of silicone oil — is performed. If the oil is removed during the postoperative period of the original vitrectomy, modifier 58 applies for a planned or staged procedure.
- EXAMPLE 6: Recurrent retinal detachment repair. A surgeon perform an RD repair with vitrectomy (CPT 67108). Three weeks later, within the global period, the patient develops recurrent retinal detachment in the same eye. The surgeon returns to the operating room to perform a pars plana vitrectomy re-repair (CPT 67108). Modifier 58 does not apply, because the second procedure was neither preplanned nor more extensive. The second surgery should be billed with modifier 78; only the intraoperative portion of the procedure is paid, because the postoperative period runs concurrent with that of the original procedure. RP