Notification



Notification Issue Date:



Claim Payment 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 #:03.00.12e

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

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 during 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.
    • 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 applies the Medicare Physician Fee Schedule Data Base (MPFSDB) assigned percentage for the intraoperative care.
  • Refer to the Coding Table in this policy for a link to 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.

It is inappropriate to report Modifier 78 with a procedure code in the following situations:
  • When all the requirements listed above for the appropriate reporting of Modifier 78 are not met.
  • When the same procedure as the initial procedure, as represented by the same procedure code, is performed by the same professional provider or other qualified health care professional on the same date of service. In such cases, refer to the Cross References section for a link to the policy that addresses Modifier 76.
  • Modifier 78 should not be reported for subsequent procedures that are performed after the postoperative period of the initial procedure has ended.

The following applies when claims are received with procedure codes appended with Modifier 78 and such services meet all policy requirements:
  • The postoperative period of the initial procedure remains intact.
  • A new postoperative period does not apply to the subsequent procedure.
  • Procedure codes appropriately appended with Modifier 78 are not subject to the global surgical package; postoperative period rules apply to the initial procedure.
  • Multiple surgical reduction guidelines may apply when multiple subsequent procedures are performed on the same date of service.

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: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and 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.

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 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.

The postoperative period for a major surgical procedure is 90 days. The postoperative period for a minor procedure is 0 or 10 days.
References

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12 - Physicians/nonphysician practitioners. 40.2: Billing requirements for global surgeries. [CMS Web site]. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.


CPT Professional Edition: Current Procedural Terminology (Current Procedural Terminology, Professional Ed. (Spiral): American Medical Association (AMA); 2016 Edition

Understanding Modifiers (Optum Learning Series) (Optum Learning: Coding & Reimbursement Educational); 2015 Edition.




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 Attachment A for Current Procedural Terminology (CPT) codes that are appropriate to be reported with Modifier 78 when all the requirements in the policy are met.


Refer to Medicare's Physician Fee Schedule Search page to perform a search using the Pricing Information search option. Scroll-right to the column that corresponds to Intra Op:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html



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 or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period


Coding and Billing Requirements


Cross References


Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 01/01/2016
Version Issued Date: 12/31/2015
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.