Rules for modifiers continue to confound. This month we look at modifier 58 and identify when it should — and should not — be used.

Q. What is modifier 58?

A. CPT defines modifier 58 as a “Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period.” CPT continues, “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 does modifier 58 differ from modifier 78?

A. Place of service is a key discriminator. CPT defines modifier 78 as an “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. In addition, modifier 78 causes a reduction in reimbursement; only the intraoperative portion of the procedure is paid because the original procedure’s global period continues.

Modifier 58 does not change reimbursement and the postoperative period restarts for the second procedure.

Let’s consider some cases:

1. Injection of triamcinolone acetonide for CME after cataract surgery.

One week after cataract surgery with implantation of an IOL, the patient complains of poor vision. An OCT identifies CME. An intravitreal injection (CPT 67028) of triamcinolone acetonide is performed in the office 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. Remember that all physicians of the same specialty within a group practice are treated as though they are the same person; so, even if the injection is given by the retinal specialist in the group rather than the cataract surgeon, these rules still apply.

2. Repair wound dehiscence following blepharoplasty.

Three days after a blepharoplasty procedure (within the global period), the patient returns with an open wound from rubbing her eye. Two broken sutures are noted on exam. The surgeon cleans and resutures the lid in the office. Modifier 58 does not apply because the repair was not planned; it is part of the postoperative care for a complication.

3. Injection of 5-FU following trabeculectomy.

At the conclusion of a trabeculectomy (CPT 66170), the surgeon’s operative report indicates that 5-FU injections within the bleb are planned to control scarring. One week later (within the global period), the first subconjunctival injection (CPT 68200) of 5-FU is performed in the office. Modifier 58 does apply to this example, as it is a related, planned procedure done in the office.

4. 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 does apply to this example, as it is a planned procedure that will be done in the office.

5. 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 does apply to this example, as it is a related, more extensive procedure.

6. Planned removal of silicone oil following vitrectomy.

Silicone oil is injected in cases of a chronic retinal detachment, proliferative vitreoretinopathy (PVR), advanced diabetic retinopathy, macular holes and other disease processes that require long-term tamponade of the retina following vitrectomy.

To avoid any long-term complications, surgeons plan to remove the oil once the eye is relatively stable. Ultimate stability is not achieved until this final staged procedure ­— the removal of the oil — is performed. If the oil is removed during the postoperative period of the original vitrectomy, modifier 58 does apply, as this is a planned or staged procedure.

7. Failure of initial RD repair requiring a more extensive repair.

A surgeon performs an 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. Repair is re-performed, but it is significantly more complex (CPT 67113). Modifier 58 does apply to this example, as it is a related, more extensive procedure.

8. Incomplete removal of a malignant skin lesion requiring a larger excision and repair.

A surgeon removes a malignant skin lesion from the eyelid (CPT 11640). The pathologist’s report indicates that the margins are not clear — some cancer remains.

One week later (within the global period), a surgeon performs an excision and repair (CPT 67966) to remove the remaining neoplasm and to fix the defect. Modifier 58 does apply here, as it is a related and more extensive procedure. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .