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 policy applies to professional and outpatient facility claims.
Modifier 78, used to indicate an unplanned return to the operating/procedure room required for a related procedure or service performed by the same professional provider or other qualified health care professional during the postoperative period of the initial procedure, is eligible for reimbursement consideration by the Company when all of the following requirements are met:
- The subsequent procedure or service is performed by the same or a different professional provider or other qualified health care professional in the same provider group.
- The subsequent procedure or service is performed on the same day or within a major or minor surgical 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 or service 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 or service is not a repeat of 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.
- Refer to the Coding Table in this policy for direction on how to access MPFSDB 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 in the following circumstances:
- When all the requirements for the appropriate reporting of Modifier 78 are not met.
- The subsequent procedure or service is not performed in an OR, cardiac catheterization suite, laser suite, procedure room, or endoscopy suite.
- The subsequent procedure or service, is a repeat of the initial procedure represented by the same procedure code and 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 policy regarding Modifier 76: Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional.
- The subsequent procedure or service is unrelated to the initial procedure.
- In such cases, refer to the policy regarding Modifier 79: Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
- The procedure or service is performed after the postoperative period of the initial procedure has ended.
- The procedure or service is unrelated to the initial procedure.
- The initial 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 pre-payment reviews and post-payment 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.
When more than one subsequent procedure is performed on the same date of service and meets the all policy requirements listed above, each procedure code must be reported with Modifier 78.
Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.