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Basics of CPT Modifier 79, 78 and 58

Reporting procedures and services performed in the outpatient setting may create a challenge for coders when a return to the operating room for a related or unrelated procedure or service becomes necessary. There are different modifiers used for outpatient setting like 59, 76, 77, 58, 78, 79 etc. but each one of them has to be used very carefully. Now we have new modifiers XE, XP, XS and XU along with 59 modifier for providing more specific information about the procedure performed. However, few modifiers like 58, 78 and 79 modifier has to be understood clearly since it can be confused other modifiers. Modifiers are little tricky to understand, if you know how to use them then you can easily answer any question on modifiers in Certified Professional coder exam. Let us first know the full description about modifier 58.

Modifier 58, Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

When to Use 58, 78 and 79 modifier in detail

Modifier 58 is utilized to identify those situations when a procedure or service may be staged (planned). While a return to the operating room for a related procedure may be commonplace, a staged (planned) procedure or service may not be as routine. I will try to clarify the intent when to exactly use Modifier 58 with procedure codes. As per the CPT coding guidelines, Modifier 58 is assigned for any subsequent procedure, which is planned or has to be performed with the related original procedure. Following three key points should be remembered before appending modifier 58 to the procedure codes.

a. Planned or anticipated (staged)

b. More extensive than the original procedure

c. For therapy following a surgical procedure.

If any of these criteria is mentioned, we can use Modifier 59 with CPT codes. In addition, modifier 58 may be utilized if a diagnostic endoscopy results in the decision to perform an open procedure. In this situation both procedures may be reported with modifier 58 appended to the HCPCS/CPT code for the open procedure.

Modifier 58 Simple Example

A surgeon performs a biopsy on a patient. The results indicate that the sample is cancerous. The surgeon performs a second procedure to remove the cancer. Use modifier 58 when billing for the second procedure

When we should not use Modifier 58

I already told before we can get confused with other modifiers while using Modifier 58. Here is the best example for unplanned return of the patient for any related problem of the original procedure. Such cases occur only when patient get some complication from the original procedure. In such cases, we have to use Modifier 78, which is used for unplanned return to the operating room.

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

Never use Modifier 58 for surgery CPT codes like 67208 which state“1 or more sessions or 1 or more visits” in the code narrative. The procedure should be staged or planned, the used of modifier 58 is not based on the number of visits.

Do not use Modifier 58 or 78 when any diagnostic procedure is turned into an open procedure. In such case, we will code the most complex procedure that is open procedure CPT code. The diagnostic procedure will get included in it. As per NCCI guidelines, if any planned laparoscopic procedure fails and is converted to an open procedure, only the open procedure is separately reported.

Finally, use of Modifier 58 is only within the global period. If the patient does not visit within the global period of the original procedure, use of modifier 58 or 78 is not appropriate.

The use of modifier 78 is not limited to complications. It can be used when the doctor didn’t plan or know of the need for the second procedure until after the first.

For example, a physician removes cataracts from both of a patient’s eyes. Vision in the left eye quickly returns to normal; however, vision in the right eye requires a YAG laser capsulotomy. The second procedure was unplanned, in the postoperative period, and performed by the same surgeon, thus, you may append modifier 78 to the procedure code.

Payment policy indicators of Physician Fee Schedule should be checked for assigning correct modifiers.

000 = Endoscopic or minor procedure with related preoperative and postoperative relative value units on the day of the procedure only, included in the fee schedule payment amount
010 = Minor procedure with preoperative relative values on the day of the procedure and postoperative values during a 10-day postoperative period included in the fee schedule amount
090 = Major surgery with a one-day preoperative period and 90-day postoperative period included in the fee schedule payment amount
MMM = Maternity codes. The usual global period does not apply.
XXX = Global concept does not apply
YYY = Palmetto GBA will determine whether the global concept applies and establish a postoperative period, if appropriate
ZZZ = Code is related to another service (‘add-on’ code) and is always included in the global period of the other service

Examples for Modifier 58, 78 and 79

Example 1

A patient has Central Venous catheter(36560-36571) placed in Chest. The Catheter has after few days gets malfunctioned. The patient suddenly visits to his physician within global period or postoperative period because of the catheter complication. Now, the physician performs the replacement of the Central venous Catheter. Now, because of the unplanned return of the patient to the operating room during postoperative or global period, the replacement CPT code (36580-36590) will be appended with Modifier 78.

Example 2

Now if a patient had a removal of a breast lesion (CPT 19120) followed in less than 90 days by the removal of the entire breast (CPT 19307). The second procedure is more extensive than the original procedure and the documentation supports for the planned or staged procedure. In such cases, we will bill CPT 19307 with 58 modifier for the second procedure.

When to use Modifier 79

Modifier -79 is used to explain that a patient requires surgery for a condition totally unrelated to the condition for which the first operation was performed.

Modifier 79 – Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

For example, a patient had an appendectomy and two weeks later had a gallbladder episode that necessitated removal of the gallbladder. Modifier -79 would be placed on the cholecystectomy code, indicating that the subsequent procedure was unrelated to the first procedure.

Avoid using 79 Modifier when

When the two surgeries are related.
When a different physician performs the operation.
When the operation happens outside the post-op period.
When the procedure is performed somewhere other than the operating room.

Differentiate 78 From 79 modifier

Append modifier 79 to surgery codes to indicate that an unrelated procedure was performed by the same physician (or a physician of the same specialty in the same surgical group) during the postopera- tive period of a previous procedure. In other words, look to modifier 79 when the second procedure is not a result of the initial surgery or the diagnosis that prompted it.

Modifier 79, like modifiers 58 and 78, describes a return to the OR by the same doctor during the global period of another proce- dure; however, modifier 79 indicates that there is no connection between the subsequent procedure and the initial surgery. As such, the unrelated procedure is usually linked to a different diagnosis.

When you append modifier 79 to a code, it starts a new global period. A new postoperative period begins when the unrelated procedure is billed, and the second procedure should be reim- bursed at 100 percent of the allowed amount, as determined by the carrier.

Discerning when to use modifiers 58, 78, and 79 is understandably difficult, as they seemingly overlap. Just remember: Modifier 58 typically describes “going beyond” the initial intervention — a more extensive procedure, a procedure performed in stages, or providing therapy following a diagnostic procedure — while modifier 78 is for an unanticipated return to the OR to fix a problem created by the first surgery. And when the provider performs two unrelated procedures, with the second being in the global period of the first, append modifier 79 to the second of the two procedures.

Modifier 79 Examples

1. A surgeon amputates a patient’s right little finger because of an infection. Within the postoperative period of this surgery, the same physician amputates the patient’s left little toe after it is crushed in an accident. Modifier 79 would be used on the second surgery because the two operations are completely unrelated, even though they may seem similar.

2. A physician performs exploratory surgery on a lump discovered in a patient’s forearm. The lump turns out to be a benign cyst. Within the post-op period, the same patient returns to have a fibroma removed by the same physician. The two incidents are unrelated, so modifier 79 is used.