CPT Modifier 58

Description
Staged or related procedure or service by the same physician during the postoperative period.

Guidelines/Instructions
Submit CPT modifier 58 to indicate that the performance of a procedure or service during the postoperative period was either:
  1. Planned prospectively at the time of the original procedure (staged);
  2. More extensive than the original procedure; or 
  3. For the therapy following a surgical procedure
  • Do not submit this modifier on assistant surgery services because global surgery rules do not apply to assistants. Services submitted with CPT modifier 80–82 in addition to CPT modifier 58 will be "returned as unprocessable" with remark code MA130. CPT modifier 58 should be removed and the service(s) resubmitted with CPT modifier 80–82.
  • Special instructions for submitting this modifier with eye surgery codes: CPT codes 65855, 66762, 67101, 67105, 67141, 67145, 67208, 67210, 67218, 67227 and 67228
    • It is generally not appropriate to submit CPT modifier 58 with these CPT codes. The narrative descriptions for these codes include the phrase "one or more sessions." The intent of this phrase, as used in the descriptor of a CPT code, is to include all sessions in a complete defined treatment period.
    • The defined treatment period is determined by the physician performing the service and varies with respect to the individual patient, the diagnosis and the location of treatment. For Medicare purposes, this means the defined global surgery period.
    • These CPT codes should be reported once for the defined global surgery period to include all sessions during that period
    • Example: for laser photocoagulation of diabetic retinopathy requiring four sessions, you would report CPT code 67228 once
    • This includes the surgery and appropriate follow-up, post-operative management, over the ensuing 90-day global surgery period
    • If a new or different condition appears within the global period, use an appropriate modifier to indicate the treatment is not part of the original series (see CPT modifiers 78 and 79)
    • If repeat treatment is necessary after the global surgery period because of disease progression, a new treatment or series of treatments should be reported using the appropriate code. In this case, the repeat treatment represents a new defined treatment period.
  • Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See CPT modifier 78.
  • Examples for correct submission of CPT modifier 58:
    • Example 1: A staged or planned procedure. A patient presents to the OR on May 1 for a cheek-to-nose skin flap. The operating surgeon performs the formation of a pedicle flap (CPT code 15576). The flap is formed and attached to the nose, maintaining the blood supply from the cheek. On June 1 (within the global period of the previous surgery), the flap is divided and is permanently inset at the nose (CPT code 15630). Submit CPT modifier 58 with CPT code 15630 to indicate that the procedure was planned prospectively.
    • Example 2: More extensive procedure. A right breast lesion removal (CPT code 19125) is performed on May 1 and was positive for cancer. On May 8, (within the global period of the previous surgery), a modified radical mastectomy including axillary lymph nodes, with or without pectoralis minor muscle (CPT code 19307) was performed. Submit CPT modifier 58 with CPT code 19307, since the mastectomy procedure was a more extensive procedure than the lesion removal.
    • Example 3: Planned additional therapy, two different physicians: an incisional biopsy of the prostate (CPT code 55705) was performed on May 1. On May 8, the patient was returned to the Operating Room for further treatment to place interstitial radiation (CPT code 77778) at the site of the prostate cancer. One surgeon performed the biopsy; a different surgeon performed the other procedure. Unless the surgeons are of the same specialty and same provider group, CPT modifier 58 is not needed.

References:

  • CMS Pub. 100-04, Chapter 12 (PDF, 1.12 MB), Sections 40-40.5 (40.2 A6, 40.3 C, 40.4 A)
  • CMS Pub. 100-04, Chapter 23 (PDF, 1.82 MB) in the Addendum at the end of the chapter

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