Review Question - QID 213164

When billing for the second stage of this patient’s care, the surgeon would bill for each procedure (i.e., spacer removal and bone grafting), with each procedural code appended with modifier 58 to signify this was part of a staged procedure while the patient is within the global period from his first surgery.

Modifier 58 is appended to a subsequent staged, anticipated, or more extensive surgical procedure during the global period. This modifier typically is appended to a subsequent surgical procedure when the disease process requires additional surgical intervention for management of the entire condition (for another example, it would be appended to the procedures performed in the second stage of a prosthetic joint infection). Modifier 58 may be appended only during the global period and restarts the global period. When using modifier 58, the physician expects 100 percent reimbursement for the subsequent procedure(s).

Rubenstein 2015 provides a review article regarding commonly used modifiers. Specifically, he describes Modifier 58 (staged procedure within the global period), Modifier 59 (distinct procedural service), Modifier 76 (repeat procedure), Modifier 78 (subsequent or related procedure/ service within a global, unplanned return to the operating room), and Modifier 79 (unrelated procedure/ service by the same provider within the global period).

Esposito et al. 2020 as part of a three-review series provide the latest of their reviews on surgical billing. This third section deals with coding of additional select procedures, modifiers, telemedicine coding, and robotic surgery. They report on the multiple uses of Modifier 58. They describe that when appending a procedural code with this modifier for a staged procedure, the subsequent/staged portion of the procedure can be within a stated plan of care, or it can be implied, executing a more extensive procedure because the original procedure did not achieve the desired outcome as planned.

Incorrect Answers:
Answer 1: Modifier 25 is appended to claims for an Evaluation and Management (E&M) service provided to indicate that a significant, separately identifiable E&M service was performed by the same physician on the day a minor procedure was performed. For example, if a provider performs an intra-articular knee injection (and therefore would bill for the procedure code) but then also performs a different/separate Evaluation and Management service on the same day (such as E&M of a shoulder injury in the same patient), he would also bill the appropriate CPT code for E&M appended with modifier 25.
Answer 3: Modifier 59 describes a distinct procedural service and is used to identify procedures and services that are not normally reported together. This modifier is used for procedures that occur during the same encounter. For example, Modifier 59 should be used when coding for a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion (noncontiguous lesions in different anatomic regions of the same organ), or separate injury.
Answer 4: Unlike modifier 58, modifier 78 does not indicate a “planned, staged, or anticipated” return to the OR. Modifier 78 is appended to a subsequent procedure that requires a return to the OR for an unplanned condition. Most commonly this will be due to a complication at the surgical site.
Answer 5: Modifier 79 is appended to an unrelated procedure during the global period. The patient is in a 10- or 90-day global period for a surgical procedure and requires a surgical intervention for an unrelated condition (typically at a different anatomic location) during that time. Modifier 79 is only appended during the global period of an initial unrelated procedure. Because modifier 79 is unrelated, 100 percent reimbursement is expected and overlapping global periods are created.