One or Two Operative Notes? Modifier 58 Needed for Front-Back Spine Surgery?

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February 6, 2014

Question:

My neurosurgeon is starting to do anterior and posterior spine surgeries on the same day. We’ve been advised to dictate two operative notes and use the staged procedure modifier, 58, on the codes. Is this correct?

Answer:

You might be interested in the article I wrote for the North American Spine Society on this subject. (Click here for neurosurgery articles). Modifier 51 is most appropriate in this instance where you are doing multiple procedures on the same day/same patient/same anesthetic/same operative session. Only one operative report is necessary. In fact, it creates a lot of confusion when more than one is dictated in this situation.