Barbara J. Cobuzzi, MBA

Modifiers 58, 78, and 79 are all used in conjunction with procedures performed within the global period of another procedure. Below we will review when each modifier is used and give examples for each.

Coders often have a difficult time discerning when to use a 58 modifier versus a 78 modifier. One quick and easy way to differentiate is to ask yourself why the physician is doing the additional procedure in the global period. If it is because of the 

 which created the global period, then there is a good chance that the appropriate modifier is going to be the 58 modifier. However, if the reason for the new procedure is because of a 

 and not the original condition, i.e., a complication of the original procedure such as a post-operative wound infection or a post-operative hemorrhage, the 78 modifier may be more appropriate. Here is a little more detail:

 The modifier 58 is defined by CPT as “staged or related procedure or service by the same physician during the post-operative period.” It may be necessary to indicate that the performance of a procedure or service during the post-operative period was a) planned or anticipated (staged); b) more extensive than the original procedure; or c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure.

This modifier has multiple uses. Some people think that the physician has to specifically state planned stages in order for a procedure to qualify for the 58 modifier. This is not the case. The subsequent procedure can be within a stated plan of care, or it can be implied, executing a more extensive procedure because the original procedure did not achieve the desired outcome as planned.

1) Is the original condition is being treated?

2) Is the subsequent procedure more extensive than the first because the desired outcome was not accomplished?

3) Is something being done to “finish” what was started with the prior procedure?

4) Is a procedure being done to facilitate therapy, or is it therapy following a prior procedure?

 to any of these questions will direct you to the 58 modifier.

 Modifier 78 is defined by CPT as “unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the post-operative period. When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure.” This is providing care as an outgrowth of the 

Modifier 78 has two caveats attached to it:

1) The patient must be returned to the O.R. or endoscopy suite to qualify for the 78 modifier. Unlike modifiers 58 and 79, 78 

may not be performed anywhere but in the O.R.

2) The reason for the subsequent surgery is related to the original surgery, meaning that there is a complication of the surgery requiring a return to the O.R. or endoscopy suite.

 or service by the same physician during the post-operative period.” It is used in the strictest sense for care that is entirely unrelated to the prior surgery that created the current global period.

For example, a patient who is in the post-op period for arthroscopic shoulder surgery may fall and fracture their leg. Care of their leg is unrelated to the global period created by the shoulder surgery and therefore, any procedure for the leg would have a 79 modifier appended. Services that qualify for a 79 modifier may be performed anywhere.

is president of CRN Healthcare Solutions in Tinton Falls, N.J., a healthcare consulting firm. Cobuzzi is also a senior coder and auditor for The Coding Network and a past member of the American Academy of Professional Coders (AAPC) National Advisory Board and Executive Board. She has served as an expert witness on both civil and criminal fraud cases, and has written for many key publications in the medical coding and reimbursement industry. She may be reached via 

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Here's advice on understanding and differentiating the use of modifiers 58, 78, and 79 at your medical practice.

Understanding Modifiers 58, 78, 79

Templates are a useful tool for documenting the evaluation and management (E&M) service, but remember, they can also make it very easy to document a higher level of service than provided. As long as your templates are consistent with the medically necessary service for your patient’s presenting problem, and not just force feeding extra components for a higher level of E&M service, they are working for your practice.

Payers and auditors worry on a regular basis that templates are contributing to “level creep,” the systematic increase in E&M levels supported by documentation through the use of either paper or EHR templates. From a systems point of view, templates are the correct tool to prompt the clinician, giving them the clues they need to document various history components, exam bullets, and medical decision making elements.

However, if the results these templates generate are not consistent with the true nature of the presenting problem (NPP), they can become instead an inaccurate tool for providing and documenting a higher level of service for your patients. This is not how your practice should operate as it may give your payers and/or auditors a dim view of your use of templates. Keep in mind that as the clinician you are ultimately responsible for limiting how extensively templates are used, the level of E&M service documented, and the degree of E&M service provided.

Where do you start when using templates? The extensiveness of your patient’s history and its contribution to the complexity and nature of the presenting problem will determine how much of an exam is needed. So, using a template to gather and document a comprehensive history is good medical care, as long as the physician conducts an exam that is dictated by the NPP. If the problem is straightforward, the exam should be problem focused or expanded problem focused at most, so even with a template, no more than this limited exam is required.

Letting the NPP dictate the level of service will guard against level creep, where the template is leading the physician to provide more services than those that are medically necessary. The medical decision making component will then flow from the appropriate exam and history. By using this methodology, even with the use of templates, the physician will not over document or provide more services than necessary. So remember, when using templates - or just evaluating how much work you are going to be doing - keep in mind the patient’s NPP and current history. If you do that, the medical necessity should become clear, prompting you to provide no more or no less than the patient’s problem requires.

is president of CRN Healthcare Solutions in Tinton Falls, N.J., a healthcare consulting firm. Cobuzzi is also a senior coder and auditor for The Coding Network and a past member of the American Academy of Professional Coders (AAPC) National Advisory Board and Executive Board. She has served as an expert witness on both civil and criminal fraud cases, and has written for many key publications in the medical coding and reimbursement industry. 

Templates are a useful tool for documenting the evaluation and management service, but remember, they can also make it very easy to document a higher level of service than provided.

Using Templates Well

In light of the expansion of Medicare’s Recovery Audit Contractor program, physicians are taking a second look at their coding practices. Don’t make the mistake of undercoding because you think it is the safe way to go. If you document well, and let the nature of the presenting problem (NPP) become the prevailing criterion for selecting an E&M code, you should be able to defend any audit that comes your way.

Start where all E&M services begin, with the chief complaint. When gathering a history it is clinically appropriate to conduct a comprehensive history for a new patient, even one who presents with a simple problem. This allows you to insure that this problem is truly straight forward; or you may uncover complicating factors such as comorbid conditions, familial history, medications that may affect the problem, etc.

Performing a comprehensive history for even a seemingly small problem can help you conclude whether the chief complaint is truly small, or if the NPP has been complicated by some aspect of the history. There is a reason why the history has three elements: history of present illness; review of systems; and past family and social history - and all three are required to determine the NPP. 

The next two steps build on the first. Based on the chief complaint, the history, and ultimately the NPP, you will then decide how extensive an exam is needed. For a straight forward, simple problem, the exam will match it, and will only need to be either a problem-focused or expanded problem-focused exam. Even though a comprehensive history may have been performed and documented, the NPP will lead you to a limited exam, thus limiting the level of the E&M service performed and documented for that encounter.

Had the comprehensive history uncovered a slightly more complex presenting problem, you may have determined it was necessary to perform a more detailed exam. By doing this, you are setting up the service for a higher level E&M code based on the more complex presenting problem.

And finally, had the problem been determined to be very complex, you would have determined that a comprehensive exam was necessary for this encounter.

This leads you to the medical decision making element of the E&M service. Often the medical decision making calculation does not align with the NPP, especially for established patients with chronic illnesses. Because these patients may not be able to support a high number of diagnostic management options or diagnostic testing, it is difficult to justify a higher level of medical decision making. However, the NPP - for example the management of diabetes, HIV, Lupus, or other chronic conditions, particularly when they may not be totally in control - can support a level four follow-up visit from a medical necessity standpoint.

So, even though the medical decision making component by itself can only support a low E&M code due to the familiarity of the patient’s case, performing and documenting a comprehensive interval history and a detailed exam (medically necessary for the nature of these presenting problems) supports the level four established patient. This is why it is so important to consider the NPP and not just the medical decision making element of the E&M calculation.

In light of the expansion of Medicare’s Recovery Audit Contractor program, physicians are taking a second look at their coding practices.

Uncovering the Right Code

Have you ever tried to use modifier 59 (Distinct procedural service)? From its description, it might seem like a magic bullet. You can split two procedures (bundled by the Correct Coding Initiative, or CCI) so each can be paid separately. Sounds great.

But be careful. If you don’t properly justify its use, modifier 59 can turn poisonous, abusive, and possibly fraudulent - not what you want. 

There are two legitimate reasons to unbundle codes that the CCI considers bundled: When they are performed during different encounters in the same day, and when the procedures were performed on separate anatomical sites. 

The Department of Health and Human Services’ Office of the Inspector General has targeted inappropriate use of modifier 59 for scrutiny because some providers appear to use the modifier as a “license to unbundle” without being able to justify the “separate site” or “separate encounter.”

To use modifier 59 successfully, first understand why it exists and when to use it.

- Say a physician performs a diagnostic nasal endoscopy (31231 - 

Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]

). Later that day, the patient shows up in the emergency room with a nose bleed. The same physician is called in and he performs a cautery of the nose bleed (30903 - 

Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method

). These two codes are normally bundled together - control of bleeding is considered part of the endoscopy procedure - but since they were done in separate patient encounters, the use of modifier 59 is appropriate and the physician will be paid for both codes. 

Since 30903 is the Column II code (considered bundled into 31231), you append modifier 59 to it. You would code 31231 (with the diagnosis for the earlier encounter) and 30903-59, 784.7 (

). Tricky part: You don’t always append modifier 59 to the second procedure performed; you append it to the column II code in the pair. 

 - Another reason to use modifier 59 is to notify the payer that although two codes are normally bundled, they describe procedures that were done on different anatomical locations. Performing bundled codes on different locations does not qualify them for bundling, but payers’ software will automatically bundle the codes and only pay for the column I code. Use modifier 59 to notify the payer of this special circumstance. 

For example, a patient is in the operating room for a biopsy of her left breast and a partial mastectomy of her right breast. The surgeon is performing the partial mastectomy of the patient’s right breast since a prior biopsy has shown a lesion there to be malignant. A breast biopsy (19101 - 

) is bundled into a partial mastectomy (19302 - 

Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]; with axillary lymphadenectomy

). In order to get paid for both, you might think that just putting an LT modifier on 19101 and a RT modifier on 19302 would work, but it doesn’t. Many payers, including Medicare MACs/Carriers, don’t pay based on the LT and RT modifiers. In order to break the bundle, you must append modifier 59 to the column II code, 19101. The service, indicating separate sites in the same encounter, could be 19302, 174.9 and 19101-59, 239.3 (the diagnoses could differ, depending on the documentation). 

For consistent success with using modifier 59, think like a bundler: Consider the mindset of the CCI editors when they created a bundle. If a different device is needed to perform the second procedure, it is likely the editors of CCI factored that into the bundle. Simply switching devices does not make it a separate service. If you scope two separate locations which are defined by two different codes, it is highly likely that those creating the CCI bundle expected that would happen, so modifier 59 is not justified just because you examined two locations; it’s implicit in the bundle. 

Err on the side of safety when considering modifier 59, and document well. Then if you do get called out on using it, make sure that when you take the stand in a fraud and abuse case or a refund request, you can fully defend your actions.

is president of CRN Healthcare Solutions in Tinton Falls, N.J., a healthcare consulting firm. Cobuzzi is also a senior coder and auditor for The Coding Network and a past member of the American Academy of Professional Coders (AAPC) National Advisory Board and Executive Board. She has served as an expert witness on both civil and criminal fraud cases, and has written for many key publications in the medical coding and reimbursement industry.

Have you ever tried to use modifier 59 (Distinct procedural service)? From its description, it might seem like a magic bullet.

Author | Barbara J. Cobuzzi, MBA

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