Medical Auditing Practice Exam

What modifier should be appended when reporting both a diagnostic endoscopy and an open procedure performed by a GI physician?

1. Modifier 25

2. Modifier 58

3. Modifier 59

4. Modifier 91

The correct answer is: Modifier 58

When reporting both a diagnostic endoscopy and an open procedure performed by a GI physician, the appropriate modifier to use is the one that indicates the additional procedure is a staged or related procedure during the same session. Modifier 58 signifies that the second procedure is planned or anticipated and is related to the first procedure, indicating that both were part of a planned course of treatment. In the context of endoscopic procedures, a diagnostic endoscopy may often lead to the necessity of a more invasive procedure, such as an open surgical intervention. Using modifier 58 in this situation effectively communicates to insurers that the two procedures are connected, representing a continuum of care rather than two distinctly unrelated services. This is particularly important for ensuring proper reimbursement and avoiding denials for services rendered in the scope of a single medical event. Other modifiers, such as 25, 59, and 91, serve different purposes and would not appropriately apply in this context. For example, modifier 25 is used to indicate a significant separately identifiable evaluation and management service, which does not pertain to the relationship between diagnostic and surgical procedures in this scenario.