CurrentPremera BluecrossPolicy N/A

Modifier 58 - Staged or Related Procedure or Service by Same Physician or Other Qualified Healthcare Professional during Postoperative Period

Defines when Premera recognizes CPT modifier 58 for staged or planned related procedures performed during the postoperative global period and the documentation and billing implications for professional claims.

Policy Summary

PayerPremera Bluecross

PolicyModifier 58 - Staged or Related Procedure or Service by Same Physician or Other Qualified Healthcare Professional during Postoperative Period

Policy CodePolicy N/A

Change TypeAnnual reviewno changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument prospective plans in the member's medical chart for returning the patient to the operating room for additional procedures during the initial surgery's global period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

resets global periodEffect on global period

no 58 with 78/79Prohibited combos

Premera & affiliatesOrganizational scope

When Modifier 58 Is Recognized

Modifier 58 coverage and billing criteria

Covered when ALL of the following are met:

Modifier 58 may be appended to a service to indicate a staged or related pre-planned procedure performed during the global period by the same physician or other qualified healthcare professional.

Appending modifier 58 to another surgical service breaks the global period of the first procedure and resets the global period based on the subsequent staged procedure.

Documentation in the member's medical chart must indicate prospective plans for returning the patient to the operating room for additional procedures during the global period of the initial surgery.

Modifier 58 should not be appended to procedure codes whose CPT description indicates 'one or more sessions' (examples: 41530, 66762, 67208, 67210, 67218, 67220, 67229) because their RVUs already reflect multiple sessions.

Policy Summary

PayerPremera Bluecross

PolicyModifier 58 - Staged or Related Procedure or Service by Same Physician or Other Qualified Healthcare Professional during Postoperative Period

Policy CodePolicy N/A

Change TypeAnnual reviewno changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument prospective plans in the member's medical chart for returning the patient to the operating room for additional procedures during the initial surgery's global period.

SourceLink

On This Page

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Relevant Modifiers and Example CPT Codes

Modifiers referencedModifier

Modifier 58	Staged or Related Procedure or Service by Same Physician or Other Qualified Healthcare Professional during Postoperative Period
Modifier 76	Repeat Procedure by the Same Provider
Modifier 78	Unplanned return to the Operating Room for a Related Procedure
Modifier 79	Unrelated Procedure/Service by the Same Provider During Postoperative Period

CPT examples where modifier 58 should not be usedCPTNot Covered

41530	Example CPT with 'one or more sessions' - do not append modifier 58
66762	Example CPT with 'one or more sessions' - do not append modifier 58
67208	Example CPT with 'one or more sessions' - do not append modifier 58
67210	Example CPT with 'one or more sessions' - do not append modifier 58
67218	Example CPT with 'one or more sessions' - do not append modifier 58
67220	Example CPT with 'one or more sessions' - do not append modifier 58
67229	Example CPT with 'one or more sessions' - do not append modifier 58

Documentation and Billing Requirements for Modifier 58

Documentation Required

Documentation Required for Modifier 58

Documentation in the member's medical record must indicate prospective plans for returning the patient to the operating room for additional procedures during the global period of the initial surgery. The chart should clearly describe the staged or related subsequent, pre-planned procedure and the clinical rationale tying it to the original operation.

Applies when modifier 58 is appended to indicate a staged or related subsequent pre-planned procedure
Records must document prospective plan for return to the OR during the initial surgery's global period
Modifier 58 should not be used for CPT codes defined as 'one or more sessions' (e.g., 41530, 66762, 67208, 67210, 67218, 67220, 67229)

Billing Rule

Billing Rule for Modifier Use

Modifier 58 resets the global period when used appropriately for a staged or related subsequent pre-planned procedure by the same provider. Do not bill modifier 58 with modifier 78 or 79 on the same service. For treatment of an unrelated surgical problem or complication that requires a return to the operating room during the postoperative period, use modifier 79 instead.

Modifier 58 indicates a staged or related subsequent pre-planned procedure and breaks/resets the global period
Never append modifier 58 with modifier 78 or 79 on the same service
Use modifier 79 for unrelated procedures during the postoperative period
Multiple surgical reductions may be applied when more than one surgery is rendered during the subsequent return trip to the operating room

Modifier Definitions

Modifier 58

DefinitionStaged or related subsequent pre-planned procedure performed during the global period by the same physician or other qualified healthcare professional; appending modifier 58 breaks the global period of the first procedure and resets the global period based on the subsequent staged procedure.

Documentation requirementMedical chart or records must indicate prospective plans for returning the patient to the operating room for additional procedures during the global period of the initial surgery.

Codes excludedDo not append modifier 58 to CPT codes that state 'one or more sessions' (examples: 41530, 66762, 67208, 67210, 67218, 67220, 67229).

Claim typeRecognized when submitted on a professional claim (CMS-1500/837P).

Modifier 76

DefinitionRepeat procedure by the same provider used to indicate a repeated basic procedure or service after the original procedure or service.

Use guidanceAppend modifier 76 when the same physician or other qualified healthcare professional repeats a procedure after the original service.

Relation to 58Use modifier 76 for repeats; modifier 58 is for planned staged procedures that reset a global period.

Modifier 78

DefinitionUnplanned return to the operating room for a related procedure during the postoperative period.

Use guidanceAppend modifier 78 for treatment of a problem or complication that requires an unplanned return trip to the operating room for a related surgical procedure by the same provider.

Prohibition with 58Do not bill modifier 58 with modifier 78 on the same service.

Modifier 79

DefinitionUnrelated procedure/service by the same provider during the postoperative period.

Use guidanceAppend modifier 79 for a return to the operating room for an unrelated surgical procedure during the postoperative period.

Prohibition with 58Modifier 58 should never be billed with modifier 79 on the same service.