Q If a patient delivered vaginally but had to have a dilation and curettage for retained placenta, can I use a modifier -58 (staged procedure) or -78 (related procedure)?
A If the patient required the postpartum curettage after she left the delivery suite, the modifier -78 (return to the operating room for a related procedure during the postoperative period) would be the correct modifier. If the curettage occurred while she was still in the delivery suite, the correct modifier would be -51 (multiple procedures). You can only use -58 (staged or related procedure or service by the same physician during the postoperative period) when the procedure was planned ahead of time, was more extensive than the original procedure, or was a therapeutic procedure following a diagnostic procedure, and of course never if the procedure occurs at the same operative session as the delivery.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.