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Modifier 58

It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure.


Examples:

When to use modifier 58

Scenario 1
A patient with gangrene has his toe amputated. But on follow-up, it is determined the patient actually needs to have the rest of his foot removed because the original procedure didn’t completely take care of the problem.

Scenario 2
A pedicle flap is performed to reconstruct a soft tissue defect of a finger. Three weeks later a division and inset is performed.