Modifier 58 Verus 78 Depends On Planning

By Author: erinartice
Total Articles: 106
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Last October, a patient had extracorporeal shock wave lithotripsy, which carries a 90-day global (for a ureteral stone). The patient came back after a couple of months in December last year with pain and an x-ray showed the stone unchanged in the ureter. As such, the urologist carried out a ureteroscopy and stone extraction. I billed this to the insurance with a modifier 58, however it is being denied. How should I go about this situation?

You're still in the 90-day global of the extracorporeal shock wave lithotripsy (ESWL); however, you're now providing a more invasive surgical procedure. Your coding for the treatment of the same stone that stays in the same location in the ureter and appears to have not been fragmented by the ESWL is proper coding.


Add modifier 58 (Staged or related procedure or service by the same doctor during the postoperative period) to point to the more invasive nature of the present treatment, the ureteroscopy. But even though your coding is proper, the carrier may review this scenario as a complication of the initial ESWL and require modifier 78 on the ureteroscopy ...
... code 52352 in place of modifier 58.


What's more: It is likely that this payer does not recognize modifier 58. If it does not, even with documentation and an appeal, the claim will not be paid.


But then since the second procedure was more invasive, and if your urologist's documentation read this, and the insurance company does recognize 58, then you should appeal.


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