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Second Surgery Coding: Tips for Modifier 58, 78 Success

Posted on 19. Jan, 2010 by in Hot Coding Topics

Don’t let ‘unplanned’ lead to ‘unpaid.’

The next time a patient takes an extra trip to the operating room, don’t let the added service throw your coding off track. Keep these tips in mind to know when to assign modifier 78 – or something else.

Check for Surprise Versus Planned

Two modifiers pertain to follow-up trips to the OR, but knowing the basic difference helps you choose the right one:

• Modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) represents an expected return to the OR. This could be because the original surgery normally is performed during multiple sessions or the follow-up is more extensive than the original procedure. “The patient’s condition dictates the additional service or the service was planned prior to the original surgery,” explains Linda Parks, office manager for Herrin Family Medicine in Lilburn, Ga. You can also report...

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