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Analysis

Reporting Requirements for Modifier -58

By Revenue Cycle Advisor  
   September 25, 2020

Since the mastectomy is a staged/planned and therapeutic procedure performed after a diagnostic service, modifier -58 is appropriate.

A version of this article was first published September 25, 2020, by HCPro's Revenue Cycle Advisor, a sibling publication to HealthLeaders.

Q: When would it be appropriate to report modifier -58 for a procedure performed during the postoperative period?

A: Modifier -58 is defined as a staged or related procedure performed during the postoperative period of the first procedure by the same physician. A staged procedure is one that is planned or anticipated.

It would be appropriate to report modifier -58 if the procedure or service performed during the postoperative period meets one of the following criteria:

  • It is for therapy following a diagnostic surgical procedure.
  • It is more extensive than the original procedure.
  • It was planned prospectively or at the time of the original procedure.

Consider the following example:

A patient with diabetes and advanced circulatory problems came in for a surgical procedure to have a gangrenous toe removed from her left foot. On the day of the procedure, the physician let the patient know that her condition was progressing and that she may need to have her left foot amputated. A couple weeks later, the physician performed an amputation of the patient’s left foot.

The physician or physician coder would report these services as follows:

  • 28820, amputation, toe; metatarsophalangeal joint
  • 28805-58, amputation, foot; transmetatarsal

As a reminder, the above example is for professional fee billing.

The following is an example that a facility coder might see:

A patient presents for an outpatient breast biopsy with the potential for mastectomy depending on what is found on the frozen section. The provider finds that the frozen section reflects the need for a simple mastectomy.

The outpatient facility (and the surgeon) would report these services as follows:

  • 19101, incisional breast biopsy (assuming this is the method used for biopsy)
  • 19303-58, simple mastectomy, staged

Since the mastectomy is a staged/planned and therapeutic procedure performed after a diagnostic service, modifier -58 is appropriate.

Editor’s note: This question was answered by Sarah L. Goodman, MBA, CHCAF, COC, CHRI, CCP, FCS, and Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, CPAR, CPC, COCduring the HCPro webinar, “2020 Modifier Update: Guidance for Effective Hospital Reporting.”

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Revenue Cycle Advisor combines all of HCPro's Medicare regulatory and reimbursement resources into one handy and easy-to-access portal. News is not just repeated from other sources. It is analyzed by our Medicare experts so professionals can comprehend any new rule and regulatory updates thoroughly. Learn more.


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