Modifier 78-Unplanned return to the Operating Room for a Related ...

Professional Services ClaimsCoding PolicyTitleNumberLast ApprovalDateReplacesCrossReferenceModifier 78-Unplanned return to the Operating Room for a Related ProcedureCP.PP.240.v2.101/11/15 Original 01/01/05Effective DateN/AModifier 58 – Staged or Related Procedure or Service by the Same Physician or OtherQualified Healthcare Professional during Postoperative PeriodModifier 79 - Unrelated Procedure/Service by the Same Provider During PostoperativePeriodGlobal SurgeryCoverage of any service is determined by a member’s eligibility, benefit limits for the service or services rendered and theapplication of the Plan’s Medical Policy. Final payment is subject to the application of claims adjudication edits common to theindustry and the Plan’s professional services claims coding policies. Reimbursement is restricted to the provider's scope of practiceas well as the fee schedule applicable to that provider.Purpose To define when the Plan recognizes services appended with Modifier 78.ScopeApplies to all Company lines of business and products with the exception of MedicareAdvantage.PolicyThe Plan recognizes Modifier 78 when appended to a procedure warranting anunplanned return to the operating room, by the same physician or other qualifiedhealthcare professional, during the global period of the initial procedure for a relatedprocedure during the postoperative period.Procedure global periods are established and identified in the current CMS NationalPhysician Fee Schedule (NPFS). Global periods for unplanned surgeries do not restartor begin a new global period.If the unplanned return is for an unrelated procedure and both are performed by thesame provider who performed the initial service, use Modifier 79 instead.If the return to the operating room was “planned” or a “staged procedure”, use Modifier58 instead.Reimbursement for services appended with Modifier 78 will be adjusted to reflect anunplanned return to the operating room.Violations ofPolicyViolations of this policy by any party that enters into a written arrangement with thePlan may result in increased auditing and monitoring, performance guarantee and othercontractual penalties and/or termination of the contract. Disciplinary actions will beappropriate to the seriousness of the violation.Violations of this policy may be grounds for disciplinary action. The level of disciplineis at the discretion of the Company, and may include any of the following: (1) verbalwarning; (2) written warning; (3) suspension; (4) termination; and (5) restitution.ExceptionsNone1This policy was published on January 14, 2015.© 2015 PREMERA. All Rights Reserved.

Laws,NoneRegulations &StandardsReferences • American Medical Association’s Current Procedural Terminology (AMA/CPT)codebook• Centers for Medicare and Medicaid Services• National Physician Fee Schedule (NPFS)Policy OwnerReviewContactAnnual ReviewDatesProvider Billing Integrity Oversight CommitteeAny questions regarding the contents of this policy or its application should be directedto the Payment Policy Department.01/11/15; 01/12/14; 01/13/13; 01/26/12; 01/27/11; 02/12/10; 03/24/09; 06/16/08;04/11/06; 08/29/05; 06/27/05; 07/30/042