March 26, 2015

Question:

What modifier do you suggest I use when we do anterior/posterior spine procedures on the same patient at the same operative session on the same day? My coder thinks we should use modifier 58 (staged) but I remember you saying, at AANS coding courses, not to use modifier 58. Please help.

Answer:

You’re correct! Modifier 58, staged procedure, is used when the procedures are performed on different dates of service. When you perform the procedures on the same date of service you will use modifier 51 (multiple procedures). Both procedures should be dictated on one operative note so there is no confusion about what was done and when.