Modifier 78: Appropriate Use
Modifier 78: Unplanned Return to Operating Room
Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period
Modifier 78 is used to report an unplanned return to the operating or procedure room, by the same physician, following an initial procedure for a related procedure during the postoperative period. The gist of that is, choose modifier 78 for a related operation that wasn’t planned in advance. For example, a surgeon does a biopsy. The site gets infected, and the patient has to come back for a second operation to remove the infection.
- To identify a related procedure (that has 10 or 90 global surgery period) requiring a return trip to the operating room within the postoperative period of a major or minor surgery.
- To treat the patient for complications resulting from the original surgery
- When the procedure code used to describe a service for a treatment of complications is the same as the procedure code used in the original procedure.
- On any procedure code that does not have global period of 0010 or 0090.
- When surgery is unrelated to the original procedure.
- On procedures performed in any place other than the operating room.
- Procedure codes that have 10 or 90 global days on the Medicare Physician Fee Schedule database (MPFSDB) are paid at the intra-operative percentage displayed on the MPFSDB. The procedure’s fee schedule amount is multiplied by the percentage and rounded to the nearest cent.
- Procedure codes that have 0 global days on the MPFSDB are paid at the full fee schedule amount.
Basic Guidelines for Modifier 78
Submit this modifier to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure) when the subsequent procedure is related to the first and requires the use of an operating or procedure room.
- This modifier may only be submitted with surgery codes
- An operating room for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit unless the patient’s condition was so critical there would be insufficient time for transportation to an operating room.
- No additional documentation is required with the claim. Supporting documentation must be maintained in the patient’s medical record. The documentation must substantiate that the surgeries are related and that the subsequent surgery required a return to the O/R.
- If the subsequent surgery is unrelated to the initial surgery and both are performed by the same surgeon, refer to CPT modifier 79
- If the subsequent surgery is related to the initial surgery but does not require a return to the operating room, and both are performed by the same surgeon, the subsequent surgery cannot be submitted separately. The global fee for the initial surgery includes additional related surgical procedures that do not require a return to the operating room.
- E/M services on the same day as a procedure with 0 or 10 global days are generally not payable separately from the procedure.
- E/M services on the day of the procedure and during this 10-day postoperative period are generally not payable.
- If a (subsequent) bilateral procedure requires a return to the operating room after the initial surgery and the Bilateral Indicator in the MPFSDB is 1 or, do not submit CPT modifier 50. CPT modifiers 50 and 78 cannot be submitted for the same service. Instead, submit the surgery procedure code with CPT modifier 78 and HCPCS modifier RT on one detail line, and submit the same surgery procedure code with CPT modifier 78 and HCPCS modifier LT on a separate detail line.
Examples of Modifier 78
A patient has an open reduction of a fracture of the distal end of the femur with the insertion of pins. While still hospitalized, the patient develops a postoperative infection, and it is determined that the patient is experiencing an allergic reaction to the pins. The patient is returned to the operating room to have the pins removed. The second procedure (removal of pins) would be billed with modifier 78.
A physician removes cataracts from both of a patient’s eyes. Vision in the right eye quickly returns to normal. However, vision in the left eye requires a YAG laser capsulotomy. Modifier 78 is used. The second procedure was performed in the post-operative period, by the same physician. However, the doctor didn’t plan or know of the need for the second procedure until after the first.
A physician performs a caesarian section on a patient. Because of bleeding, the patient is called back into the OR for a second procedure. The second procedure was unplanned, in the postoperative period, and performed by the same surgeon. Therefore modifier 78 is applied to the claim.
Modifiers © Copyright 2021 American Medical Association
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