Category: Article

Today’s article will focus on three modifiers that are not new, but are critical for all surgery coders to understand: modifiers 58, 78, and 79. All three modifiers may be reported when a procedure is performed during the global period of a prior procedure. Let’s start with a look at how these modifiers are defined and some helpful tips that can ensure you use them appropriately.

• Modifier 58: Modifier 58 is often thought of as the “staged” modifier. While that is partially correct, modifier 58 has more to its definition:
  • Use modifier 58 when a procedure performed during the global period was planned at the time of the initial procedure (e.g. a colectomy is performed with the abdomen left open intentionally, and then the patient is brought back to the operating room for planned closure of the abdomen two days later) –or-
  • When the procedure performed in the global period is more extensive than the initial procedure (e.g., a breast mass is excised, but when the pathology comes back as cancer, a lumpectomy is performed in the global period) –or-
  • For therapy following a diagnostic surgical procedure (e.g., a patient undergoes open thrombectomy and then thrombolysis therapy is started a few days to resolve residual clots during the global period)

• Modifier 78: Modifier 78 is reported for an unplanned return to the operating room when the procedure performed during the global period is related to the original procedure:
  • Use modifier 78 when treatment of a complication of the initial surgery results in a return trip to the operating room (e.g., a surgeon performs an open aortic valve replacement and then has to take the patient back to the operating room 2 days later to control mediastinal bleeding) –or-
  • When the procedure performed in a global period is related to the original procedure and was not planned at the time of the initial surgery (many examples may apply but most often you will see treatment of complications) –or-
  • When the same CPT code is reported for treatment of complications in the global period of a prior procedure (e.g., the surgeon performs ORIF of the radius, but the patient suffers a re-fracture due to her osteoporosis and a fall at home so ORIF is repeated in the global period)

• Modifier 79: Modifier 79 is reported for an unrelated procedure performed in the global period of the original procedure:
  • Use modifier 79 when a completely unrelated procedure is performed in the global period of the original surgery (e.g., initial surgery is ORIF for hip fracture and second surgery is ORIF for a humerus fracture) – or-
  • When the same CPT code is reported for the surgery performed in the global period of the original procedure, but does not represent the same procedure performed at the same anatomic site (e.g., cataract surgery on the left followed by cataract surgery on the right in the global period)

Here are some additional tips for using global modifiers correctly:

• Global modifiers are used when the patient has a second surgery in the global period with the same surgeon or a surgeon in the same specialty/group practice:
  • Do not apply global modifiers if the patient is in a global with a surgeon outside your practice.
  • Do not apply global modifiers if the patient has a procedure with a surgeon in a different specialty in the same group practice (e.g., patient had surgery with orthopedics which put them in a global but then has a procedure with cardiology in the global period)
• Modifier 78 specifically requires a return to the operating room:
  • An operating room may be formally labeled an operating room or could be an equivalent space (e.g., procedure room, cath lab)
  • For Medicare and payers following Medicare’s guidelines, do not code the treatment of complications that do not require a return to the operating room separately (e.g., incision and drainage of a wound infection in the office). Check the policies for your private commercial carriers to see if they follow Medicare or have their own policy.
• Modifiers 79 and 58 may be reported for procedures that occur in the operating room during a global period, or they may be reported with unrelated or staged procedures/therapy that occur outside of the operating room, but still in the global period.
• Each CPT code is assigned a global indicator on the Medicare Physician Fee Schedule: 000, 010, 090, MMM,XXX, YYY, ZZZ:
  • The first three indicators refer to the number of global days for that procedure (i.e., 010 is assigned to a code with 10 global days)
  • MMM indicates a maternity code, and the usual global period does not apply
  • XXX indicates that the global concept does not apply
  • YYY indicates a code where the Medicare contractor determines how many global days apply
  • ZZZ indicates a code that is related to another service and always included in the global period (e.g., add on code)
  • Why does this matter? Many Medicare contractors state that you should not apply modifiers 58, 78, or 79 to a code with an XXX or ZZZ global indicator because these codes will be allowed without any global modifier. Some payers may just view the modifier as not required, but others may consider it an error and reject a claim if you apply the global modifier to a code with those indicators. So be aware of that guidance and check your global indicators when assigning these modifiers

Finally, a great place to get additional information about how to use global modifiers correctly is in fact sheets published by your local Medicare Administrative Contractor (MAC). To find these sheets, you can Google “modifier __ (e.g., 78) fact sheet,” and you should get search results right at the top for fact sheets from your MAC. Here are a couple of examples from Novitas and Noridian:

I hope that is a helpful refresher for you on global surgery modifiers. One of the great things about coding is that no matter how long you have been in the field, there is always more to learn!

Q. How is an extensive arthroscopic debridement of the shoulder defined in CPT?

A. An extensive arthroscopic shoulder debridement (CPT 29823) is coded when three or more discrete structures in the same shoulder are debrided. We will talk more about how “discrete structures” are defined in a moment.

If you’ve been coding orthopedic surgery for a number of years, you will recall that the line between a limited and extensive arthroscopic shoulder debridement prior to 2021 was a blurry one, especially in CPT itself. We had some great supplemental guidance from the AAOS and notable orthopedic surgery consultants over the years, but lining those guidelines up with language in the typical operative reports received was still a challenge.

With fresh guidelines published in 2021, the CPT manual now contains a formal definition of when we cross that line between limited and extensive debridement so we can approach this topic with more confidence. We also have a list with examples of what the AMA considers “discrete structures” within the CPT code description itself:

• The humeral bone
• The humeral articular cartilage
• The glenoid bone
• The glenoid articular cartilage
• Biceps tendon
• Biceps anchor complex
• Labrum
• Articular capsule
• Articular side of the rotator cuff
• Bursal side of the rotator cuff
• Subacromial bursa
• Foreign body(ies)

There are a couple of additional guidelines to be mindful of as you count your discrete structures to report an extensive arthroscopic debridement:

• Per the AMA, do not “count” an anatomic structure as a discrete structure to report CPT 29823 if another arthroscopic procedure is reported at that same anatomic site during the same surgery. For example, if an arthroscopic rotator cuff repair is performed, the side of the rotator cuff (articular vs. bursal) where the tear occurred would be debrided as a normal, routine part of repairing the rotator cuff tear. The articular and/or bursal sides of the rotator cuff should not then be counted as one of the 3 discrete structures to code CPT 29823.¹

• Per CMS, a limited debridement is always included in another arthroscopic shoulder procedure on the same shoulder even if the debridement is performed in a different area of the shoulder. When it comes to extensive debridement, CMS states that, with three exceptions, extensive debridement is also included in another arthroscopic shoulder procedure on the same shoulder even if performed in a different area of the shoulder. The three arthroscopic procedures which are exceptions and allow reporting of CPT 29823 when performed in a different area on the same shoulder are CPT 29824 (arthroscopic distal claviculectomy); CPT 29827 (arthroscopic rotator cuff repair); and CPT 29828 (arthroscopic biceps tenodesis). So the CMS rules are even more stringent than the rules we have from the AMA.²

Resources:

1 CPT Assistant, December 1, 2020, copyright 2020, American Medical Association

2 NCCI Policy Manual 2025, Chapter 4, Section E.7: https://www.cms.gov/files/document/04-chapter4-ncci-medicare-policy-manual-2025finalcleanpdf.pdf