Determining When to Use Modifiers -58 and -78

When retina procedures are performed during the global period of a surgery, an appropriate modifier must be appended to the CPT code for reimbursement. When an unrelated procedure is performed postoperatively in the fellow eye, for example, modifier -79 is used. However, when the surgery is related to the original procedure, either modifier -58 or -78 should be considered.

DEFINITIONS

When considering which modifier is appropriate for a related procedure, clinicians should carefully review the definitions of modifiers -58 and -78.

Modifier -58 is defined as a staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period and has three definitions for use:

1. Planned or anticipated (staged)

2. More extensive than the original procedure

3. Therapy following a surgical procedure

Modifier -78 is used for a related but unanticipated return to the OR or office procedure room by the same physician or other qualified health care professional during the postoperative period of the initial procedure.

Reporting modifier -58 will initiate a new global period for the CPT code reported. Modifier -78, on the other hand, does not prompt a new postoperative period, and the original global period remains.

REIMBURSEMENT

Using modifier -58 will provide 100% reimbursement for the CPT code submitted. Modifier -78 provides a payment for the intraoperative component of the CPT code only, as a new global period is not initiated. The preoperative component of the global surgical package is always 10%, but the intraoperative component varies based on the global period for the surgery. For example, CPT code 67113 has a 90-day global period, and the global surgical package is assigned as:

• Preoperative 10%
• Intraoperative 70%
• Postoperative 20%

As a result, CPT code 67113 reported with modifier -78 would be paid at 70%.

With procedures with a 10-day global period, for example, CPT code 67228 would have a 10% preoperative, 80% intraoperative, and 10% postoperative reimbursement, ultimately resulting in an 80% payment when appended with modifier -78.

CASE EXAMPLES

Let’s apply these principles to real-life case studies.

Retinal Detachment Repair

Case 1. During the global period of a pneumatic retinopexy, CPT code 67110, the retina becomes detached in the same eye, and additional surgery is performed, CPT code 67108.

Result. Modifier -58 would be used because this is a lesser (pneumatic) to greater (repair of retinal detachment, vitrectomy) procedure.

Case 2. During the global period of the repair of a complex retinal detachment with proliferative vitreoretinopathy, CPT code 67113, the retina is still detached in the operative eye, and the patient is returned to the OR for additional complex repair of the retinal detachment, CPT code 67113.

Result. Modifier -78 is the correct modifier, as this is an unplanned return to the OR for the same procedure.

Removal of Silicone Oil

Case 1. A patient has no vision in the fellow eye, and the surgeon decides that instead of inserting a gas bubble that would obstruct the patient’s vision for approximately 8 weeks, silicone oil should be used during retinal detachment repair, CPT code 67108. Removal of the silicone oil around 6 weeks is preplanned and documented, CPT code 67036.

Result. Because it is preplanned and documented to remove the silicone oil 6 weeks post-surgery, modifier -58 would be reported with the vitrectomy CPT code.

Case 2. During the global period of a retinal detachment repair, the patient has a complication related to the silicone oil, and the physician decides to return to the OR to remove it.

Result. As this is a complication requiring an unplanned return to the OR, modifier -78 would be used.

Intravitreal Injection

Case 1. During the global period of a vitrectomy with laser, CPT code 67040, for proliferative retinopathy with macular edema, the patient receives an intravitreal injection of anti-VEGF for diabetic macular edema.

Result. This intravitreal injection would be considered therapy following a related major surgery, modifier -58.

Case 2. A postoperative intravitreal injection of antibiotics is administered to treat endophthalmitis in the operative eye.

Result. Modifier -78 would be correct, as this is a complication and an unplanned procedure.