Teasing out the correct use

Surgery billing requires modifiers to communicate unusual circumstances, allowing payers to adjudicate your claim correctly and pay you for work performed. Knowing which surgery modifier to use — and when to use it — can be confusing. Specifically, deciding when modifiers -58 and -78 apply can be challenging, since both relate to an original surgery within a global period. Below, we review both modifiers’ CPT definitions, followed by case studies that may help provide clarity around appropriate use.

MODIFIER -58

Definition

According to CPT 2023: 58 - 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. This circumstance may be reported by adding modifier 58 to the staged or related procedure.

Modifier -58 examples

Case 1. A patient presents with a large retinal tear in the right eye. The surgeon performs an in-office, same-day laser (CPT 67145) procedure. Unfortunately, three days later the surgeon evaluates the patient and finds a retinal detachment requiring same-day surgery in the operating room. The retinal detachment procedure (CPT 67108) is more extensive than the original procedure, meeting the modifier -58 criteria. The claim for the second surgery (CPT 67108) is filed with modifier -58, resulting in full payment and a new 90-day global period.

Case 2. A patient with diabetic retinopathy and macular edema needs an internal limiting membrane (ILM) peel (CPT 67042), followed by a series of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections (CPT 67028) during the global period. When making the decision for an ILM peel, the surgeon stages (preplans) the possible postoperative injections. Three weeks after the ILM peel, the first injection takes place during the global period. The claim requires a modifier to allow payment. In contrast to case No. 1, an injection is less extensive than an ILM peel. However, the surgeon planned prospectively — or at the time of the original procedure — for the injection, so using modifier -58 is correct.

Case 3. A patient with dry eye syndrome complains of increased symptoms, and eyedrops are no longer working adequately. The provider recommends a trial of collagen plugs in the lower punctum of both eyes to determine if silicone plugs will provide long-term relief (CPT 68761-50). The patient returns 7 days later to evaluate the success of the collagen plugs, with improved symptoms. The physician inserts silicone plugs in both lower lids (CPT 68761). With this bilateral procedure, the provider appends both modifier -58 and modifier -50 to the claim. The -58 modifier is in the first modifier position, followed by modifier -50 (CPT 68761 -58, -50). A new 10-day global period starts with the placement of the second set of plugs.

Case 4. A surgeon performs uneventful cataract surgery (CPT 66984). Three days post-surgery, the patient’s lens implant partially dislocates, requiring a return trip to the operating room (OR) for IOL repositioning (CPT 66825). Historically, modifier -78 was the correct modifier. However, because the second procedure is now “more extensive” than the first (higher relative value units, or RVUs), the surgeon’s claim needs modifier -58 appended to the code for the IOL repositioning.

MODIFIER -78

Definition

Again, compliments of CPT 2023: 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

It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure.

Modifier -78 examples

Case 1. A patient with uncontrolled IOP of 54 mm Hg in the left eye undergoes a trabeculectomy procedure (CPT 66170). Ten days post-surgery, the surgeon is unable to get an IOP reading due to a leaking bleb. The surgeon takes the patient back to the OR for a same-day bleb revision (CPT 66250). Here, the surgeon would append modifier -78 to the wound-revision code (CPT 66250). Unlike modifier -58, the global period of the first surgery remains unchanged without extension.

Case 2. Two days following Descemet stripping endothelial keratoplasty surgery (CPT 65756), the patient’s air bubble is found to be insufficient to stabilize the endothelial graft while healing. The surgeon takes the patient back to the OR for a sterile re-injection of air (CPT 66020). The surgeon appends modifier -78 to CPT 66020. The global period does not change.

Case 3. A patient undergoes routine cataract surgery (CPT 66984). Two months post-procedure, the patient’s vision becomes cloudy due to aggressive posterior capsule opacification (PCO). On post-op day 65, the surgeon takes the patient to the ASC and performs a YAG laser capsulotomy (CPT 66821). Since PCO is a complication of cataract surgery, the surgeon submits the claim for the YAG procedure with modifier -78. The original post-op global period remains intact and does not change.

Case 4. A late-stage keratoconus patient undergoes a full-thickness penetrating keratoplasty (CPT 65730) in their right eye. At the two-week post-op visit, the corneal graft has dehisced nasally. The surgeon schedules the patient for a wound repair at the ASC the following day. Since the unfortunate complication is related to the original surgery, the wound revision (CPT 66250) requires modifier -78. The global period stays the same.

SUMMING UP

Understanding the nuances of and indications for modifiers -58 and -78 can help ensure correct reimbursement for related procedures performed in a global period. When it appears that both modifiers -58 and -78 apply, review the criteria above for clarification. Should both modifiers still appear suitable, know that -58 supersedes -78. Using the incorrect modifier is costly in both time and resources for the practice, so staying informed is in your best interest. OM

Laurie K. Brown, MBA, COMT, COE, OCS, CPSS is a senior consultant with BSM Consulting in Tucson, Ariz. She has experience in the ophthalmic industry holding managerial, clinical and surgical roles for more than 30 years.

Kirk Mack, COMT, COE, CPC, CPMA, is a senior consultant at BSM Consulting and is based in Galveston, Texas. He has more than 30 years of experience in the ophthalmic industry.

Brittney Irwin, COT, CPC-A, CEP, is an associate consultant within the Billing, Coding and Compliance Division of BSM Consulting. In her role, she provides ongoing billing and coding support to ensure ophthalmic regulatory compliance. Previously, she spent more than 10 years working in ophthalmology, most recently as the clinical director of a multi-specialty group.