Summary & Overview
CPT 4058F: Clinical Performance/Reporting Measure
CPT code 4058F is a CPT-designated reporting or performance measure for a specific clinical activity; the source description provided contains no narrative summary. As a nationally recognized CPT code, 4058F matters for clinical documentation and payer reporting workflows and can affect quality measurement and claims adjudication when used in electronic health records and billing systems. Key payers discussed in this publication include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of what this code represents, the likely implications for clinical documentation and quality reporting, and how major payers typically incorporate CPT reporting codes into claims and quality programs. The publication outlines available benchmarks where present, notes gaps in the source data, and summarizes the clinical context implied by a CPT performance/reporting code. Data not available in the input is clearly identified so readers understand where source limitations exist.
Billing Code Overview
CPT code 4058F has no summary available in the source description. Based on the code designation, this entry represents a specific performance or reporting measure within the CPT coding framework. Service type: Data not available in the input. Typical site of service: Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult presenting to an outpatient otolaryngology or head and neck surgery clinic with chronic sinonasal symptoms refractory to medical therapy, recurrent epistaxis, or a sinonasal mass requiring diagnostic sampling or surgical management. The clinical workflow begins with evaluation by an otolaryngologist, nasal endoscopy, and imaging (CT or MRI) as indicated. Pre-procedure steps include informed consent, review of anticoagulation, and perioperative anesthesia assessment. In the operative suite or ambulatory surgery center, the patient undergoes endoscopic sinonasal procedure under monitored anesthesia care or general anesthesia. Intraoperative steps include endoscopic visualization, targeted biopsy or excision of mucosal lesions, management of bleeding, and specimen submission for pathology. Post-procedure care includes observation in the recovery area, discharge instructions, and follow-up for pathology results and wound healing. Typical sites of service are outpatient clinic procedure room, ambulatory surgery center, or hospital operating room depending on complexity and patient comorbidity.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure | Use when a distinct E/M visit is performed in addition to the procedure on the same day |
57 | Decision for surgery | Use when the E/M service results in the initial decision to perform the surgery |
59 | Distinct procedural service | Use to indicate a separate, distinct procedure or service not normally reported together |
24 | Unrelated E/M service by the same physician during a postoperative period | Use for unrelated E/M encounters during global period |
76 | Repeat procedure or service by same physician | Use when the procedure is repeated by the same provider during the postoperative period |
77 | Repeat procedure by another physician | Use when another physician repeats the procedure |
78 | Return to the operating room for a related procedure during the postoperative period | Use for unplanned return to OR for related treatment |
79 | Unrelated procedure or service during the postoperative period | Use when performing an unrelated procedure during global period |
53 | Discontinued procedure | Use when a procedure is started but discontinued due to extenuating circumstances |
24 | Unrelated E/M service during postoperative period | Use when an unrelated E/M occurs within the global period |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 208D00000X | Otolaryngology | Primary specialty performing sinonasal endoscopic procedures and biopsies |
| 208800000X | Family Medicine | May perform minor nasal procedures in outpatient setting |
| 207L00000X | Internal Medicine | May be involved in pre- and postoperative medical management |
| 2080P0207X | Otolaryngology - Pediatric | Performs pediatric sinonasal procedures when applicable |
| 363L00000X | Pathology | Anatomic pathologists analyze surgical specimens and biopsies |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
J32.9 | Chronic sinusitis, unspecified | Common indication for diagnostic or surgical sinonasal procedures when medical therapy fails |
J33.9 | Nasal polyp, unspecified | Nasal polyps are frequently biopsied or removed during endoscopic sinus surgery |
R04.0 | Epistaxis | Recurrent or refractory epistaxis may require endoscopic evaluation and intervention |
J01.90 | Acute sinusitis, unspecified | Acute infectious exacerbations sometimes require drainage or surgical intervention |
D49.2 | Neoplasm of uncertain behavior of respiratory and intrathoracic organs | Masses or suspicious lesions in the nasal cavity/sinuses require biopsy for diagnosis |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
31231 | Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) | Often performed immediately before or during sinonasal procedures for visualization and localization of pathology |
31237 | Nasal/sinus endoscopy with biopsy, single or multiple | Commonly performed to obtain tissue samples during endoscopic sinonasal procedures |
31276 | Nasal/sinus endoscopy, surgical, with ethmoidectomy | Performed for more extensive surgical management of sinus disease in same operative setting |
30140 | Excision of lesion of nasal vestibule, external nares | Used when external nasal lesions require excision in conjunction with endoscopic procedures |
88305 | Level IV pathology, surgical pathology, gross and microscopic examination | Typical billing code for pathological evaluation of excised sinonasal tissue specimens |