Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Modifier 78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period
Policy #:MA03.008b

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

Modifier 78 (unplanned return to the operating/procedure room by the same physician or other qualified health care professional following the initial procedure for a related procedure during the postoperative period) must be reported in the following circumstances:
  • The subsequent procedure or service is performed by the same professional provider or a professional provider in the same provider group.
  • The subsequent procedure or service is performed on the same day as or within the postoperative period of the initial procedure.
  • The subsequent procedure or service requires a return to an operating room (OR), cardiac catheterization suite, laser suite, procedure room, or endoscopy suite.
  • The subsequent procedure or service is related to the initial procedure, as evidenced by any of the following:
    • The subsequent procedure is performed to treat a complication of the initial procedure. The subsequent procedure or service is performed same day as or within the postoperative period of a major or minor surgery during the postoperative period of the initial procedure.
    • An unplanned more extensive procedure is required, due to the failure of the less extensive initial procedure.
  • The subsequent procedure is not a repeat of the initial procedure.
    • The subsequent procedure code reported must be different from the procedure code reported for the initial procedure.
When more than one subsequent procedure is performed on the same date of service and meets the requirements listed above, each procedure code must be reported with Modifier 78.

When a procedure code is appropriately reported with Modifier 78, the Company reimburses the Medicare Physician Fee Schedule Data Base (MPFSDB) assigned percentage for the intraoperative care.
  • Refer to the Coding Table in this policy for direction on how to access Medicare's Physician Fee Schedule Search page to obtain the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes and the applicable intraoperative percentages.
INAPPROPRIATE CIRCUMSTANCES FOR REPORTING MODIFIER 78

It is inappropriate to report Modifier 78 with a procedure code in the following situations:
  • All the requirements for the appropriate reporting of Modifier 78 are not met.
  • The same procedure, as represented by the same procedure code, is performed on the same date of service by the same professional provider or a professional provider in the same provider group
    • In such cases, refer to the Cross References section for a link to the policy that addresses Modifier 76.
  • The procedure is performed after the postoperative period of the initial procedure has ended.
  • The procedure is unrelated to the original procedure.
  • The original procedure code does not have a postoperative period.

ADDITIONAL POLICY INFORMATION

The following applies when claims are received with procedure codes appended with Modifier 78 and such services meet all policy requirements noted above:
  • A new postoperative period does not apply to the subsequent procedure.
  • Postoperative period rules apply to the initial procedure.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, and therapies, as well as test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Policy Guidelines

This policy is consistent with the reporting requirements established by Current Procedural Terminology (CPT) and the Centers for Medicare & Medicaid Services (CMS).


Description

An individual's condition may warrant an unplanned return to the operating room (OR) or procedure room for a related procedure that is performed by the same professional provider, a professional provider in the same provider group, or other qualified health care professional during the postoperative period of an initial procedure. In such cases, Modifier 78 is reported with the procedure code that represents the subsequent procedure.


As defined by the Centers for Medicare & Medicaid Services (CMS) and applied by the Company, reimbursement for a surgical procedure includes a standard global surgical package, which includes preoperative, intraoperative, and postoperative services.


References

Centers for Medicare and Medicaid Services (CMS). MLN Booklet: Global Surgery Booklet. [CMS Web site.] September 2018. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf. Accessed October 10, 2019.

Novitas Solutions, Inc. Modifier 78 Fact Sheet. 10/10/2017. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144546. Accessed October 10, 2019.

Novitas Solutions, Inc. Global Surgery Modifiers. 11/01/2018. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144547. Accessed October 10, 2019.

Optum360. Understanding Modifiers 2019. West Salt Lake City, UT: Optum360; 2018.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes within the Intra Op column: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes within the Intra Op column: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html


Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)



Revenue Code Number(s)

N/A


Misc Code

Modifier:

78 Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period


Coding and Billing Requirements


Cross References




Policy History

REVISIONS FROM MA03.008b
12/16/2019This version of the policy becomes effective 12/16/2019. It reaffirms the Company's continued position on reporting of modifier 78.

REVISIONS FROM MA03.008a
01/01/2016This version of the policy will become effective 1/1/2016.

Revised policy number MA03.008a was issued as a result of annual policy review. The References were updated accordingly. The policy was updated to be consistent with current template wording and format.
01/01/2015This is a new policy.




Version Effective Date: 12/16/2019
Version Issued Date: 12/16/2019
Version Reissued Date: N/A