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Policy No: 112

Originally Created: 09/01/2009

Section: Modifiers

Last Reviewed:  04/01/2019

Last Revised:  04/01/2019

Approved: 04/04/2019

Effective Date:  05/01/2019

This policy applies only to physicians and other qualified health care professionals.

Definitions

Modifier 78 - Unplanned Return to the Operating/Procedure Room By the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period

Current Procedural Terminology(CPT®) modifier 78 is used to describe an unplanned return to the operating room or procedure room during the global period of the initial procedure by the same physician.

Perioperative Percentages

Pre-Op, Intra-Op, and Post-Operative percentages published by the Centers of Medicare & Medicaid Services (CMS) in the National Physician Fee Schedule Relative Value File.

Policy statement

When an unplanned return to the operating or procedure room is needed during the postoperative global period of a prior procedure, modifier 78 must be appended to the appropriate surgical code(s) to avoid denial of the service per global period policy guidelines and to ensure proper reimbursement.

Modifier 78 must be appended when the return to the operating room is for a procedure that is related to the initial procedure, occurs in the global period of that initial procedure, the provider is the same for both procedures, and the return procedure is assigned global days of MMM, 000, 010 or 090 in the CMS National Physician Fee Schedule Relative Value File.

Modifier 78 is not appropriate for use with a place of service 11 office.

Our health plan utilizes the CMS intra-operative percentages in determining reimbursement amounts for modifier 78. In the absence of an intra-operative percentage by CMS, the health plan may establish an intra-operative percentage for specific procedures.

When a provider reports an eligible procedure with modifier 78 appended, reimbursement will be:

  • The CMS determined intraoperative percentage value  for codes with a global period of 010 or 090
  • 100% of the allowed amount for codes with a global period of 000
  • 70% of the allowed amount for codes with a global period of MMM.

Additional applicable modifiers may also apply.

References

American Medical Association.  Appendix A:  Modifiers  Current Procedural Terminology (CPT), AMA Press

National Physician Fee Schedule Relative Value File. Centers for Medicare & Medicaid Services, Chapter 12, Sections 40.2, 40.4

Cross References

Global Days

Modifier 54; Surgical Care Only, Modifier 55; Postoperative Management Only; Modifier 56; Preoperative Management Only

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.