What’s the difference between Modifiers 58 and 78?

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Modifiers in Medical Coding

Understanding the Differences Between Modifiers 58 and 78 in Medical Coding

One of the most challenging aspects of medical coding is understanding modifiers. Medical coders often find themselves grappling with several questions, such as:

  • What do modifiers mean and when do I use them?
  • Which codes require modifiers?
  • Which modifiers should I append, and to what codes?
  • Do I even need a modifier?
  • What if I add a modifier and don’t need one?
  • What if I don’t add a modifier and need one?

The stress and struggle of modifiers are real. In fact, two of the most misused modifiers are Modifier 58 and Modifier 78. At first glance, they appear similar; they even share comparable language. After a long day of coding, it is easy to skim through the modifier definitions and append the wrong code. Additionally, some coders mistakenly use these modifiers interchangeably due to a misunderstanding of their definitions. However, these modifiers code for separate circumstances and cannot be used interchangeably.

Understanding Modifiers and Their Purpose

Modifiers are two-character additions to a CPT or HCPCS Level II code. These characters are either letters or numbers, preceded by a hyphen, such as this: 19318-50. The purpose of appending modifiers to procedure codes is to provide additional, necessary information about the procedure, service, or supply without changing the meaning of the code.

For example, the code 19318-50 communicates the following:

  • 19318 = Breast reduction
  • 50 = Bilateral procedure

In this instance, the doctor performed a breast reduction surgery (19318) on both breasts (50), not just one. Without modifier 50, the doctor would not receive proper compensation for all work performed. However, some modifiers, like Modifiers 58 and 78, can be challenging for medical coders to distinguish.

The CPT Manual defines Modifier 58 as a “staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period” (2023). When a procedure has Modifier 58 appended to it, the following conditions are met:

  • The procedure was planned.
  • The procedure took place during the postoperative period.
  • The procedure was completed by the physician or qualified healthcare professional who performed the initial procedure.

For example, if an initial surgeon completes a biopsy on a patient and identifies malignant cells in the sample, the surgeon may schedule and perform a procedure to remove the cancerous cells. Since this second procedure is planned and performed by the same surgeon, Modifier 58 is appropriate.

In short, both the initial procedure and the procedure performed during the postoperative period were planned and executed by the same healthcare professional. Both the patient and physician anticipated that the postoperative procedure would occur.

Modifier 78: Unplanned Return to the Operating Room

In contrast, Modifier 78 has a different meaning. The CPT Manual defines Modifier 78 as an “unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following the initial procedure for a related procedure during the postoperative period” (CPT, 2023).

From this definition, coders can deduce that:

  • The procedure is related to the initial procedure.
  • It is performed by the same physician or qualified healthcare professional.
  • It occurs during the postoperative period.
  • It is unplanned.

Modifier 78 describes a scenario where a patient goes to a facility for a planned procedure or service but, during the postoperative period, must unexpectedly return to the operating room for a related procedure. This unplanned necessity could result from complications following the initial procedure. Neither the patient nor the physician scheduled the second procedure in advance.

An example of when to use Modifier 78 is when a doctor performs a cesarean section on a patient. If the patient experiences bleeding during the postoperative period and must return to the operating room for an additional procedure by the same physician, Modifier 78 would be appropriate.

Key Differences Between Modifiers 58 and 78

While Modifiers 58 and 78 share several similarities—such as related procedures performed in the postoperative period and procedures conducted by the same healthcare professional—the crucial difference lies in the nature of the procedures:

  • Modifier 58 codes for a planned postoperative procedure or service.
  • Modifier 78 codes for an unplanned postoperative procedure or service.

The distinction between the two is evident in the coding language:

  • Modifier 58: Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period (CPT, 2023).
  • Modifier 78: Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following the initial procedure for a related procedure during the postoperative period (CPT, 2023).

By examining the coding language closely, it becomes clear that these modifiers, while similar, are distinctly different. Modifier 58 uses the term “staged,” while Modifier 78 employs “unplanned.” This highlights the importance of carefully reading and coding modifiers.

The best approach to determine which modifier to use is to evaluate whether the second procedure was planned or unplanned. If planned, choose Modifier 58. If unplanned, select Modifier 78.

Conclusion

While learning which modifiers to append to medical codes can be tricky, understanding the subtle yet significant differences between Modifiers 58 and 78 can help coders—especially novices—feel more confident in their coding practices. By reading and coding meticulously, coders can improve their skills and gain a better eye for detail, which ultimately leads to increased confidence and expertise in medical coding

References:

How to choose: Modifier 58, 59, 78, 79. MedProdDispolsal.

MCG 2023 Absolute Medical Coding Institute

About the Blogger:

Victoria Smith is an AMCI student and intern preparing for the CPC exam. She is also a writer, editor, teacher, and lifelong learner.