Modifier -58 is Added to the CPT Code When Reporting a Staged Procedure
When reporting a staged procedure, modifier -58 should be added to the CPT code. 1 This is the correct modifier to use when a procedure was planned prospectively to be performed in stages.
Understanding CPT Modifiers for Staged Procedures
Modifiers are two-digit codes that are appended to CPT codes to provide additional information about the service performed. When it comes to staged procedures, here's how to correctly apply modifiers:
Correct Use of Modifier -58
- Used for staged or related procedures performed during the postoperative period
- Indicates that the procedure was:
- Planned prospectively at the time of the original procedure
- More extensive than the original procedure
- For therapy following a surgical procedure
- Does not restart the global period
Incorrect Modifiers for Staged Procedures
- Modifier -76: Used for repeat procedures by the same physician, not for planned staged procedures
- Modifier -51: Used for multiple procedures performed at the same session, not for staged procedures
- Modifier -25: Used when a significant, separately identifiable E/M service is performed on the same day as a procedure 2
- Modifier -59: Used to identify procedures that are normally bundled but are distinct from each other
Documentation Requirements
When using modifier -58 for staged procedures, proper documentation is essential:
- Clearly document that the procedure was planned as a staged procedure
- Include details about why staging was necessary
- Document the relationship between the initial and subsequent procedures
- Ensure the medical record supports the medical necessity for the staged approach
Common Pitfalls to Avoid
- Using modifier -76 instead of -58 for planned staged procedures
- Failing to document that the procedure was planned as staged
- Incorrectly applying modifier -51 for procedures performed on different dates
- Using modifier -25 which is intended for E/M services performed on the same day as procedures 2
Billing Implications
Using the correct modifier has significant implications for reimbursement:
- Modifier -58 allows for full payment of the subsequent procedure
- Incorrect modifier usage may result in claim denials or reduced payments
- The Office of Inspector General (OIG) closely reviews modifier usage, particularly modifier -25 3
Remember that accurate coding and modifier usage are crucial for appropriate compensation and compliance with Medicare policies. Incorrect coding may result in loss of revenue and/or significant monetary penalties for a hospital or practice 4.