Modifiers 58 and 78

By Alexander Miller, MD, March 1, 2019

You perform a therapeutic wide excision on a squamous cell carcinoma that was previously incompletely removed. Do you need to append a modifier to distinguish this service from the original surgery?

There are two types of modifiers that may be applicable to procedures done during the postoperative (global) period.

The more commonly used is modifier 58: “Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period” (CPT 2019). This modifier is typically used in dermatology when a more extensive surgery is done during the first procedure’s 10- or 90-day global period. Characteristically, this occurs when — an initial surgery incompletely removes a lesion, or when based upon histopathology — an appropriate therapeutic wide excision (as for melanoma) is recommended.

The Medicare Claims Processing Manual, Chapter 12, 40.1, specifies use of modifier 58 when:

• A staged procedure is planned in advance or is determined during the initial procedure
• A subsequent procedure is more extensive than the original
• A definitive procedure is done following a diagnostic surgical procedure

The 58 modified procedure triggers the start of an appropriate new 10- or 90-day global period for the staged procedure.

Modifier 58 is not required when an unrelated surgery is done during a postoperative period (see modifier 79), when a related surgery/procedure is done outside the global period, or when a procedure is done consequent to complications from an initial procedure.

When complications from a surgical procedure require a return to an operating room or procedure room for treatment, the service may or may not be billable, and may require appending 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” (CPT 2019). Modifier 78 is appended to an appropriate CPT^® code describing the additional procedure.

What is included in a post-operative global period and is not separately reportable?

• Treatment of complications in a patient room, minor treatment room, recovery room, intensive care unit (e.g., hemorrhage evaluated and treated in a treatment room, evaluation of ecchymoses)
• Postoperative pain management
• Surgical supplies
• Dressing changes, local wound care, removal of sutures or staples

What may qualify for reporting/billing with a 78 modifier?

• Treatment of complications requiring a return to an operating room (OR)
• Additional procedure related to the first (not meeting the definition for 58 modifier use)
• According to Medicare “an operating/procedure room is defined as any place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, laser suite, or endoscopy suite. It does not include a patient’s room, minor treatment room, recovery room, or intensive care unit.”

Additional details about billing during the surgery global period and the CMS definition of an OR may be found at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf.

Examples of complications that may require a return to the OR:

• Hematoma requiring surgical opening of a flap, identification and electrodesiccation of a bleeding vessel, and re-suturing of a flap
• Wound dehiscence requiring re-suturing
• Closure revision due to focal necrosis

A return to the OR for additional treatment is reportable/billable, when appropriate, even when it occurs on the same day as the initial procedure (prior to midnight).

Example 1: You do an incisional biopsy of a suspected melanoma. The histopathology confirms a thin melanoma. You then do a therapeutic wide excision eight days after the initial biopsy. You append a 58 modifier to the excision code, as the procedure was done within 10 days of the biopsy.

Answer: Incorrect. The new CPT biopsy codes, tangential (11102), punch (11104), and incisional (11106), have zero-day global period, meaning that any medically necessary procedure or evaluation performed on any day following a biopsy does not require a modifier. In the above scenario, a 58 modifier was not necessary.

Example 2: Although you do not have an accredited surgical operating room —  you do only procedures, including laser treatments, in your office’s designated procedure room(s), which are staffed for that purpose. Treatment of surgical/laser complications, when done in these rooms, may be reportable to Medicare with an appropriate CPT code and modifier 78.

Answer: Correct. Such procedure rooms meet the Medicare definition of OR/procedure room. (Check with your state laws for their requirements).

Example 3: While in your dedicated procedure room for surgical evacuation of a postoperative hematoma under a flap repair done one day before, the patient asks you to evaluate an unrelated skin condition. You diagnose asteatotic eczema and prescribe a topical steroid ointment along with moisturizer use. You report your services as CPT 10140-78 for the evacuation of the hematoma and 99212-24/25 for the separate evaluation and management (E/M).

Answer: Partially correct. The E/M unrelated to the 90-day global adjacent tissue rearrangement procedure is appropriately reported with a 24 modifier. However, by performing an unrelated E/M service in the same room as the designated operating (procedure) room, you may disqualify the billing of the surgical evacuation of the hematoma. Check with your payers for further clarification and their policy.

Example 4: You excise a lentigo maligna on the cheek with a 1 cm margin, which clinically appeared adequate, and do a complex linear repair. The pathology report reveals an involved posterior margin. Ten days after the initial excision you do a wider excision and report the service by appending a 58 modifier.

Answer: Correct. Although the subsequent procedure was not planned, it was related to the original surgery, was required due to the presence of a positive margin, and was more extensive than the original procedure in that it enlarged the original excision diameter. This meets the definition for appropriate use of modifier 58.

Example 5: Two weeks after an excision and intermediate repair of a nasal basal cell carcinoma that was found to extend to the margins of excision, you excise the involved site with one stage of Mohs surgery. Since the Mohs procedure was related to the initial excision, you report the Mohs surgery as 17311-58.

Answer: Incorrect. No modifier is needed. The 58 modifier applies when a related procedure is done during the global period of the initial procedure. The Mohs surgery was done beyond the 10-day global period for excisions and repairs.

Cracking the Code corrections

The January Cracking the Code column, Biopsy Coding in 2019: Part 3, requires corrections.

The 2019 NCCI first quarter edits brought a multitude of changes when appending modifier 59. The NCCI PTP code pairings do not retain their previous somewhat conceptually challenging pairing characteristics. In many cases the new biopsy codes cannot be substituted for the old 11100 biopsy code in the Column 1/Column 2 pairs.

The premalignant destruction (17000, 17004), malignant destruction (17260-17286), benign (11400-1446), and malignant (11660-11646) excision codes are no longer consistently primary to the biopsy codes. This means that whenever any biopsy technique is done along with these procedures, you should consult the NCCI PTP edits to determine which code receives the modifier. Remember that add-on codes, including add-on biopsy codes, do not require a 59 modifier. Only the code which appears in Column 2 of the NCCI PTP edits, qualifies for a 59 modifier.

Please visit staging.aad.org/dw/monthly/2019/january/biopsy-coding-in-2019-part-3 for corrected examples of code pairings, as well as 2019 updates to the Medically Unlikely Edits (MUEs).

Additionally, several examples require clarification. The examples have been clarified online and are as follows, with updates in red:

Example 2: You do an incisional biopsy of a suspected scalp lentigo maligna and destroy 10 actinic keratoses with liquid nitrogen spray. You submit CPT 11106 for the biopsy and 17000 and 17003 x9 for the actinic keratoses destruction.

Answer: Incorrect. According to the NCCI PTP table, 11106 17000 biopsy destruction requires a modifier. Report the procedures appropriately as: 11106, 17000-59, 17003 x9, 11106-59.

Example 3: You have learned from the above example and are determined to do this right. You destroy eight actinic keratoses with liquid nitrogen and biopsy two separate clinically atypical nevi using the tangential technique. You submit CPT 11102 and 11103-59, for the biopsies and 17000-59, 17003 x7 for the freezing destruction and 11102-59 and 11103-59 for the biopsies.

Answer: Incorrect. Yow! Why is that? The NCCI stipulates that add-on codes do not merit a 59 modifier. That is why you will not find biopsy and other add-on codes paired in Column 2 of the NCCI PTP (Column 1/Column 2) listing. Avoid appending the 59 modifier to add-on codes, including the biopsy add-on codes 11103, 11105, and 11107.

In this case, the claim would be reported as: 11102 and 11103 for the biopsies and 17000-59, 17003 x7 for the freezing destruction and 11102-59 and 11103 for the biopsies.

Example 5: You perform three biopsies on three separate clinically deeply palpable tumors using the incisional technique and two biopsies of carcinomas atypical nevi on the right arm and back using the tangential technique. You submit CPT codes 11106, 11107 x2 for the incisional biopsies, and 11102-59, 11103 x2 for the tangential biopsies.

Answer: Correct. Appropriate hierarchical coding of the biopsies was followed. The MUE table was consulted, and it was determined that the MUE for additional incisional biopsies is 2, so it was not exceeded. The MUE for additional tangential biopsies is 6, so nothing worrisome there. The MUE for the first biopsy is always one since a primary code (11102, 11104, 11106) may only be used once per encounter regardless of how many different types of biopsies are done. In this example, 11106 is the primary code.

However, if some of the lesions are located in the same anatomical ICD-10-CM code grouping, then the payer may adjudicate some of the biopsies as “duplicate.” Stipulate the distinct locations in the “notes” section and be prepared to appeal if inappropriate payment denial were to happen.

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