|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:|
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.
- 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 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.
INAPPROPRIATE CIRCUMSTANCES FOR REPORTING MODIFIER 78
- 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.
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.
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.
Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.