Q: [Modifiers (58 & 59)] “Can you give me examples of situations that need modifiers
for CPT… especially 58 and 59?”
A: That’s a very, very broad question.
This question was designed to be answered in 5 to 7 minutes, so I can’t go through
every single modifier; however, we do have an on-demand webinar, and we’re going to
have that modifier webinar coming up next month.
So, join us on that and I’ll go over every single modifier and appendix A of the CPT
manual.
But since you asked for 58 and 59, I’ve got some specifics on that.
Here is a copy and paste from my appendix A of CPT, that’s where modifiers live.
Some people don’t even realize that when they’re brand new at coding, they see the
little shortened list in the inside cover of CPT, but they actually live in appendix
A. That’s where you want to go and make your notes and really go look at the full
blown-out definition of the modifier.
Here’s modifier58 with all my chicken scratch here: Staged or Related Procedure or Service
by the Same Physician or Other Qualified Health Care Professional during the Postoperative
Period.
My little “GP” is my reminder that this is a global package modifier.
If I’m not in the global period for this particular patient, then this modifier doesn’t
even apply, don’t worry about it.
But if you are, and now you’re doing a second stage procedure or related procedure, then
you would want to use this modifier on that second one.
Because what happens when you’re in a global period, the payer, whenever another claim
comes in by that same physician for that same patient, they’re going to bat it back at
you and say, “Nope!
Global period, we don’t pay for it.”
So, you have to use this special modifier to kind of unlock the door just to get the
claim in to be considered.
Another keypoint for modifier 58 to remember is that the global period will reset with
this stage-related procedure.
So, they asked for example, here’s one, 52601 for transurethral electrosurgical resection
of prostate.
You’ll see here that it says, for first stage, transurethral partial resection of
prostate, use 52601.
That’s the code we’re looking at.
For second stage partial resection of prostate, use 52601 with modifier 58.
This little example where it can be a staged procedure and using the same CPT code.
That’s the idea.
Another example could be cleft palate repair where they can’t fix it all in one operative
session.
They’ll do phase 1, and then will come back and they’ll do phase 2, and phase 2 is normally
within the global period of phase 1.
Let’s say it’s 90 days and they’re coming 45 days after and they’re doing the second
stage.
That’s when you would use a modifier 58 to get it in through the door.
The next modifier that was asked about is modifier 59, Distinct Procedural Service.
Under certain circumstances, it may be necessary to indicate that a procedure or service was
distinct from or independent from another procedure on the same day.
This is like a type of bundling modifier and the example I have here is an oophorectomy,
58940, where they’re removing the ovaries.
Now, part of coding that we learn is that the approach is bundled in, so in order to
get to the ovaries, you have to open up the abdomen and go in and excise the ovary.
So, that opening of the abdomen, which is a laparotomy (“laparo” means “abdomen”;
“otomy” means “cutting into”) is part of the bigger procedure of oophorectomy.
I actually had this happen to myself, a couple of hours after the surgery, I had unusual
bleeding or something going on and they had to take me back and do an exploratory lap
to see what was going on; so I actually had two laparotomies.
So, the laparotomy code is 49000 and in order to report that properly, a modifier 59 will
be put on to say that it was done at a separate time.
That’s a way to use modifier 59.
Sometimes when you do lesion excisions, the simple repair stitches is included; but if
you did several lesion excision, maybe you did stitches too for something else on the
same arm, so there’s no other modifier you could use to say RT, LT or to differentiate
it, because technically, modifier 59 is a modifier of last resort.
If there’s any other modifier or any other way to tell your story, you’re supposed
to use that method versus 59.
So, that would be a way to distinguish a true simple repair from one that’s bundled in
with the lesion excision.
Again, documentation is always going to be needed to be at the ready if you get asked
for it.
Modifiers are basically kind of like doing our taxes, we don’t send in our receipts
to the IRS, but we sign our name stating we have them if we were to be audited.
That’s what putting modifiers on, we’re saying, “Yeah, we understand this special
circumstances, we have them and we have proof, we have documentation.”
So, if it wasn’t documented, don’t do it.
Someone in the chat was asking about these X modifiers, we went over that a couple of
webinars back and we actually posted some information about that on the discussion board.
I put the link in the chat.
But per CMS, we are to use these new X modifiers; XE, XS, XP, XU instead of modifier 59 if they
apply.
So, be aware of that and check out our website for more info on it.
Here is just my little reminder, if you want a full modifier presentation, check out this
CEU on Demand Class, and that’s the URL.
You can find it on our website as well.
That’s it for my answer sheets.