Modifiers 58, 78, and 79 - Staged, Related, and Unrelated Procedures
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Defines Moda Health billing and reimbursement rules for use of CPT modifiers 58, 78, and 79 for surgical procedures performed during another procedure's postoperative global period; applies to all participating Moda entities and providers submitting CMS1500/CMS1450 claims.
Clarified when modifier 58, 78, & 79 are needed and appropriate.
Modifier Usage and Payment Rules
Modifier usage and payment criteria
Rules for billing and payment when reporting modifiers 58, 78, or 79:
ALL of the following
- Modifier 58 documentation: Modifier 58 requires documentation at the time of the original surgery showing the future procedure was planned, staged, or anticipated; acceptable supporting documentation includes preoperative documentation and the original operative report; documentation created at the time of the subsequent procedure (after the fact) does not support modifier 58.
- Modifier 79 documentation: To validate a procedure as unrelated (modifier 79), preoperative history and physicals and operative reports for the original and subsequent procedures may be requested; billing offices must either attach this documentation to the claim or be prepared to submit it upon request.
Applicable Modifiers, Global Periods, and Reporting Rules
| Modifier 58 | Staged, related or more extensive procedure during the postoperative period; planned/anticipated. |
| Modifier 78 | Unplanned return to the operating/procedure room by same physician for related procedure during postoperative period. |
| Modifier 79 | Unrelated procedure or service by the same physician during the postoperative period. |
Documentation and Submission Requirements
Attach supporting documentation or be prepared to submit on request for modifiers 58 and 79
Attach supporting documentation to the claim or be prepared to submit documentation upon request to validate staged (modifier 58) or unrelated (modifier 79) procedures. For modifier 58 this includes preoperative documentation or the operative report from the original surgery to show the subsequent procedure was planned; for modifier 79 this may include preoperative history and physicals and operative reports for both the original and subsequent procedures.
- Modifier 58: attach preoperative documentation or the operative report from the original surgery, or be prepared to submit upon request; documentation created at the time of the subsequent procedure does not support modifier 58.
- Modifier 79: attach preoperative history & physicals and operative reports for the original and subsequent procedures, or be prepared to submit upon request.
Modifier Definitions
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