What Are Modifiers In Coding – The problem comes from the ambiguity in the definition of modifiers 58 and 78. Modifiers 79 and (to a lesser extent) 59 add to the problem. There is even a reasonable amount of confusion involving the 24 modifier.
Using the wrong modifier can mean a rejected claim. Different modders also carry different repayment schemes. For example, Modifiers 59 and 78 can reduce Medicare reimbursement below 100%.
What Are Modifiers In Coding
Tip: This quick, easy-to-understand guide eliminates confusion between these closely related modifiers. Print the modifier PDF below for handy reference, or just bookmark this page.
Modifiers In Medical Coding: How To Avoid Billing Error
To say the least, knowing how to decide between modifier 58 and 78 can be a tricky game. Modifiers 59 and 79 are also playable.
Worse, most of the information currently available on the internet does not accurately explain this problem. Most articles online quote the Medicare regulations, then make the reader wade through a sea of words to try to argue what they mean.
The decision tree below is intended to facilitate the choice between modifiers 58, 78, 79 and 59. Is it the official Medicare/CPT definition? Nope. It is built from CPT rule analysis, so take it with a grain of salt.
We’ll get to an in-depth explanation in a minute. For now, and without further ado, here’s the bottom line. Click it to access the 58 PDF modifiers, so you can download them and print them for future reference.
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Modifier 58 also refers to a procedure that is “broader than the original procedure.” We’ll delve into that in a minute. For now, think of it this way: A biopsy results in surgery to remove the tumor two weeks later. The isolation procedure is “broader.” Yet it is also “prospectively planned.” That is, the more important condition is that the surgeon knows about the possibility when he performs the biopsy.
The chart above should explain how to choose modifier 58, when to choose modifier 78 and when to decide other related modifiers like 79, 59 and 24.
The chart is not an official CMS document. Instead, it was built from an analysis of the CPT modifier definitions and explanations on the CMS.gov website. This is a good rule of thumb, in other words, but it’s best to read the full definitions, conditions and examples below.
Modifiers 58, 78, 59, 79 and 24 are billing code modifiers used for surgical claims. They each have very specific, albeit related, definitions. They often cause confusion, especially between modifiers 58 and 78, but also between 59, 79, and even 24. Here are the definitions, according to Current Procedural Terminology (CPT):
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WARNING: The definitions below are from CMS.gov and are misleading. They are provided here more to point out the confusion than to clear it up. For clarity, see the decision tree above or the “How to Choose” section below.
From the definition above, the source of the confusion is clear. Modifiers 58 and 78 can refer to the same procedure, right? Both during the postoperative period. 58 can be “phased/planned,” while 78 can be “unplanned,” right? Except that 58 also says “or related.” That seems to indicate that related and unplanned procedures can use either modifier 58 or modifier 78.
Modifiers 79, 59, and 24 contain their own points of confusion. As we’ll show in a bit, the 58 and 78 modifiers are actually very different. Only the words of the CMS definition make some health care advantages.
The decision tree above should make it clear how to decide between modifiers 58 and 78. Since the two CPT billing codes are most often combined, we’ll address that first.
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We have provided an in-depth explanation and example below so readers can check our math. Use the decision tree above in other words, but don’t neglect your own due diligence.
Modifier 58 is used for “staged or related procedures or services by the same physician during the postoperative period.”
There is some ambiguity here, as nowhere in the CPT manual does CMS explain whether the above conditions are separated by “or,” or “and.” However, it is generally assumed that the condition is an “or” case. That is, any one of them can by itself trigger the use of modifier 58.
Modifier 58 covers the return to OR. It is always for related procedures. It is always during the post-operative period.
How Do I Know When To Use Modifier 59?
The key with modifier 58 is that it almost always includes a procedure that the doctor is aware of before the completion of the first relevant operation.
For example, the surgeon does a biopsy, finds cancer, and has to bring the patient back to remove the rest.
The surgeon performs a biopsy on the patient. The results showed that the sample was cancerous. The surgeon performs a second procedure to remove the cancer. Use modifier 58 when billing for the second procedure. why? Because surgeons know a biopsy may result in further and more extensive procedures, wait for test results.
The surgeon performs a procedure to clean the sacral ulcer. During the procedure, the surgeon knows he must perform a skin graft at the ulcer site later in the day. Skin grafts will be billed with modifier 58. Why? Because during the original procedure, the doctor knew the corrupt procedure was going to happen.
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Use modifier 78 for “Unplanned return to the operating room or procedure by the same physician after the initial procedure for a related procedure during the postoperative period.”
For example, a surgeon performs a biopsy. The site became infected, and the patient had to return for a second surgery to remove the infection.
Like modifier 58, modifier 78 also involves returning the patient to the OR. It is always for related procedures. It is always also during the post-operative period.
Unlike modifier 58, modifier 78 covers operations not planned by the doctor, even at the end of the first procedure.
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In other words, with modifier 78, the need for the procedure is not known until after the first procedure has finished.
A doctor performs a caesarean section on a patient. Because of bleeding, the patient was called back to the OR for a second procedure. The second procedure was unplanned, in the postoperative period, and was performed by the same surgeon. Therefore modifier 78 is applied to the claim.
A doctor removes cataracts from both eyes of a patient. Vision in the right eye quickly returned to normal. However, vision in the left eye required YAG laser capsulotomy. Modifier 78 is used. why? The second procedure was performed in the postoperative period, by the same doctor. However, doctors don’t plan or know the need for a second procedure until after the first.
Modifier 79 is like modifiers 58 and 78. It covers procedures by the same doctor in the postoperative period.
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With modifier 79, it doesn’t matter whether the procedure is planned or not during the previous procedure, because there is no connection between the different operations.
The patient’s right big toe was amputated due to infection. In the postoperative period, the same doctor amputated the patient’s right toe after it was crushed by the weight of the falling body. Modifier 79 is used. why? Because the two operations are not related at all, although they may seem similar.
A doctor performs exploratory surgery on a lump found in a patient’s arm. The lump turned out to be a benign cyst. In the postoperative period, the same patient returned to have the fibroid removed by the same doctor. The two incidents are unrelated, so modifier 79 is used.
It is similar to modifier 78 in that both refer to “unrelated” services by the same physician in the postoperative period.
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Any E/M service billed under modifier 24 must have documentation to support that the service was not part of postoperative care for the original procedure.
A surgeon performs a procedure to repair a hernia. In the postoperative period, the patient returned to the same doctor to evaluate the lump on his arm. The second procedure uses the modifier 24. Why? Because the two procedures are unrelated and because the second procedure is an E/M procedure.
A doctor performs ACL surgery on a patient. In the postoperative period, the same surgeon evaluated the patient for wrist pain. The second visit is billed under modifier 24.
Modifier 59 is used for procedures/services that are “different or independent from other non-E/M services performed on the same day…”
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The CPT definition of modifier 59 is actually longer than that, but we can stop there. why? Because we’ve got all the information we need. We can already clearly distinguish it from transformer 58 and transformer 78, as well as 79.
Consider: Modifiers 58, 78, and 79 all refer to “unrelated E/M procedures/services or services in the postoperative period.”
One point of confusion between modifier 59 and modifier 79 is that both can refer to unrelated non-E/M services or procedures performed during the postoperative period. why?
Because A) modifier 59 refers to same-day service and B) the postoperative period can technically begin on the “same day.”
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While that is true, “same day” is more specific, so modifier 59 should be used instead of 79 for same day, non-E/M service.
The above explanation should indicate that modifier 59 is different from modifiers 58, 78 and 79. For further clarification, only use modifier 59 when the procedure/service
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