When billing for an unplanned return to the OR that is related to the original procedure, use modifier 78.
CPT® modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period) indicates all of the following circumstances:
• A subsequent procedure has occurred during the global period of a previous service.
• The subsequent procedure is related to the original surgery, but not to the underlying condition that prompted that surgery. In other words, the diagnosis linked to the subsequent procedure will describe a new condition (i.e., a complication of surgery) that will differ from the diagnosis linked to the initial surgery.
• The initial and subsequent procedures involve the same patient and the same provider. Note that under Centers for Medicare & Medicaid Services (CMS) guidelines, the "same physician or other qualified healthcare professional" includes providers within the same physician group, billing under a common National Provider Identifier (NPI).
• The subsequent procedure was unanticipated/unplanned at the time of the initial procedure.
You should append modifier 78 to the CPT® code that describes the subsequent procedure. Modifier 78 is not applicable for those codes that include the terms "subsequent" or "reoperation" (e.g., 33011, Pericardiocentesis; subsequent).
CPT Assistant Sept. 2010 provides the following coding example:
• A partial colectomy was performed in the hospital on March 1. The postoperative period for this procedure (code 44140) is 90 days. On March 15, the patient was returned to the operating room for treatment of partial dehiscence of the incision with secondary suturing of the abdominal wall. The secondary suturing was related to the original surgery.
• CPT code reported for the first procedure: 44140
• CPT code and modifier reported for the second procedure: 49900-78
Because suturing of the abdominal wall was an unplanned procedure within the global period of the initial procedure to treat a complication, reporting modifier 78 indicates to the third-party payer that the procedure is related to the first procedure. The preoperative and postoperative care services, which are usually a part of the surgical package for a surgery, are not included when modifier 78 is used.
Medical necessity must support a return to the OR
To use modifier 78 appropriately, the patient must be returned to the OR. For example, the General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1 states, "Control of postoperative hemorrhage is … not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable with modifier 78."
CMS defines an OR "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 OR)."
If the provider is able to treat the complication without a return to the operating room, Medicare will bundle the treatment into the initial procedure's global surgical package. Chapter 12 of the Medicare Claims Processing Manual specifies, "The global surgical package includes all medical and surgical services required of the surgeon during the postoperative period of the surgery to treat complications that do not require return to the operating room."
Modifier 78 does not reset global days from the previous surgery. Typically, you will not receive full reimbursement for the surgery to treat the complication. Most insurers reimburse only the intra-operative portion of the standard fee schedule payment (approximately 80 percent of the total).
Avoid confusion with similar modifiers
Use caution when selecting between modifier 78 and modifier 79 (Unrelated procedure or service by the same physician or other qualified healthcare professional during the postoperative period.) Although both modifiers describe a return to the OR during the global period of another procedure, modifier 79 indicates the subsequent procedure is unrelated to the initial surgery. In other words, the "follow-up" procedure was neither a result of the initial surgery, nor the diagnosis that prompted it. When you append modifier 79 to a claim, a new global period begins and the subsequent procedure is paid at 100 percent of the allowed amount, as determined by the carrier.
In some cases, modifier 58 (Staged or related procedure or service by the same physician during the postoperative period), rather than modifier 78, may properly describe a return to the OR during the global period. The Medicare Claims Processing Manual Chapter 12, Section 40.1.B states, "If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately." In such circumstances, modifier 58 is appropriate.