Modifier 78

Modifier 78 Description, Uses, Guidelines & Examples (2022)

Modifier 78 appends for service when the physician performs an unplanned return to the operating or procedure room by the same physician following the initial procedure for a related procedure during the postoperative period.

Modifier 78 Description

78 adds to CPT codes when the same physician performs a service related to prior surgery or procedure. For example, modifier 78 applies when the operating room requires a related service or surgery and only attaches to the service in the postoperative period. 

Modifier 78 indicates another unplanned surgery or service performed by the physician or a skilled professional during the postoperative period of an initial procedure. For example, the patient had a surgical procedure on the right shoulder and may present again and require a service for complications developed in the prior surgery.

78 does not apply to the Evaluation and Management CPT codes (99201-99499). It is appropriate to append modifiers 24, 25, 57, etc., when E/M visits bills for the service. 

Modifier 78 frequently bills with surgical procedures when the physician requires repeat service for unplanned return of the related condition of initial surgery.

Modifier 78 is only applicable when service renders in a 10 or 90 days global period. It is inappropriate to bill for an unrelated service or previously scheduled service.

Modifier 78 bills more often with surgical procedure codes as CPT codes range from 10000 to 60000 procedure codes and ma report with radiological service if the insurance or third-party payer requirements.

Unlike modifiers 58 and 79, Modifier 78 impact the payment of the following service performed by the physician in the postoperative. The physician was not reimbursed for 100 percent because pre and postoperative services have already the part of prior surgery and paid.

What Is Modifier 78?

Modifier 78 represents the service when the same physician performs a service related to prior surgery or procedure. For example, 78 applies when the operating room requires a related service or surgery and only attaches to the service in the postoperative period. 

When To Use Modifier 78

Modifier 78 appends with the service when the physician does not plan the procedure, and the patient returns to the operating room due to complications related to the prior surgery. For example, the patient may have developed an infection or complications at the surgical site.

The second procedure must be related to the prior service or surgery to append 78.

The other procedure must perform in the operating room after the initial service or surgery.

78 Modifier is not confined to complications but may also have other reasons. For example, it may apply to prior surgery or procedure problems. 

78 modifier

Modifier 78 Guidelines

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.  

Modifier 78 is applicable with service when the procedure or service is not planned or staged during prior related surgery. Therefore, it is appropriate to append a 58 instead of 78 when the physician performs planned or staged service. 

Modifier 78 is irrelevant to attach unrelated service to the prior surgical procedure, and it is appropriate to append modifier 79 with that service instead of 78.

78 Modifier is only applicable when the physician performs the service during the 10 or 90 days postoperative. Therefore, it is inappropriate to append 78 on the day of surgery or after the postoperative period.

Modifier 78 is only applicable when the same physician performs the service during the 10 or 90 days postoperative. Therefore, when furnished by a different provider, it is inappropriate to append 78.

78 Modifier does not apply to evaluation and management procedures (99201-99499). It is appropriate to report with E/M Modifiers 25, 24, 57, etc.

Modifier 78 is only applicable when the same physician performs the service in the operating room during the 10 or 90 days postoperative. Therefore, it is inappropriate to append 78 when furnished in other than the operating room.

Modifier 78 vs 79

Modifiers 78 and 79 apply when the same physician performs the service during the postoperative period. Modifier 78 is appropriate when the physician provides service to the patient for an unplanned return to the operating room following the initial procedure for a related service during the postoperative period.

In Contrast, Modifier 79 append with services unrelated to the procedure or service performed in the postoperative period. It usually represents the unrelated procedure to the prior surgery within a ten or 90-day global period.

For Instance, the physician saw the patient during the postoperative period and performed an Umbilical hernia repair procedure before this encounter, which has 90 days global period. However, the patient needs another service because an infection developed on the surgical site and was not a planned return. Therefore, it is appropriate to report the other procedure with Modifier 78.

Similarly, Suppose the Patient returns to the provider for an unrelated procedure in the postoperative period, such as a malignant tumor excision of the head region. In that case, it is entirely unrelated to umbilical hernia repair, and It is appropriate to report Tumor excision of the head region with modifier 79.

Modifier 58 vs 78

Modifiers 58 and 78 apply when the same physician performs the service during the postoperative period. Modifier 58 influences the global period and starts the global period of the new procedure. It will result in full payment by the insurance or third-party payer. 

Modifier 58 is a subsequent staged, planned, or more extensive procedure than the prior surgical procedure. Therefore, it does not require a return to the operating room. 

In Contrast, Modifier 78 is an unplanned return to the operating room after the initial procedure. It will influence or break the previous global period of prior surgery. The physician may perform the following service for the complications of previous surgery and not planned return.

For Instance, the physician saw a patient and performed a procedure such as a mastectomy on the right upper quadrant. The physician plans to perform another operation after two weeks as there are still some lesions left in the right upper quadrant of the breast. Therefore, the patient returns to the same provider in the postoperative after two weeks for lesion removal, and It is appropriate to report the lesion removal with modifier 58.

Similarly, Patients return to the provider with massive bleeding in the right upper quadrant of the breast where the previous procedure performs by the physician. This new procedure did not plan by the physician and returned due to the complications related to the prior service.

Does Modifier 78 Reduce Payment?

The use of modifier 78 reduces the procedure payment according to their respective physician fee schedule. In addition, 78 indicates the procedure complication which causes the patient to unplanned return to the operative room or endoscopy suite or catheterization in the postoperative period.

The insurance or third-party payer reimburses 70-80 %of the allowable amount to the provider, and they only pay the fee for the intraoperative procedure as pre and postoperative already been paid to the provider in the global period. 

Modifier 78 Examples

The following are the examples of when modifier 78 appends with the CPT codes:

Example 1

A 36-year-old male presents to the office for complications developed on the procedure site on April 4, 2022, and has KNEE ARTHROSCOPY/SURGERY on March 1, 2022. The physician redoes the procedures which are related to KNEE ARTHROSCOPY/SURGERY.

Modifier 78 appends the procedures performed on April 4, 2022, to unbundle the service with CPT code 29881, which has a 90-day global period. Therefore, it will not influence the postoperative period.

Documentation must support the medical necessity of these two services KNEE ARTHROSCOPY/SURGERY and new procedure performs due to complications on the same day for accurate reimbursement by the insurance or third-party payer.

Example 2

A 46-year-old male presents to the physician for an emergency department visit on December 2, 2022, with infections developed on the surgical site and had a procedure for Inguinal hernia repair on January 23. The physician operates on Inguinal hernia repair related to the prior surgery.

Modifier 78 appends to the procedures performed on December 2, 2022, to unbundle the service with CPT code 49505, which has a 90-day global period. Therefore, it will not influence the postoperative period.

Documentation must support the medical necessity of these two services, such as Inguinal hernia repair and other procedures performed on the same day for accurate reimbursement by the insurance or third-party payer.

Example 3

A 76-year-old male presents to the physician for – Combined right and left heart catheterization and had an ED visit for infections developed on the surgical site and Enterectomy by the same Physician 60 days ago. In addition, the physician operates to repair the suture sites of prior Enterectomy, which is related to the previous surgery. Suppose CPT codes 44120 and 99284 bills for these services. 

Modifier 78 appends to the procedures performed today to unbundle the service with CPT code 44120 performed 60 days ago, which has a 90-day global period. Therefore, it will not influence the postoperative period.

Documentation must support the medical necessity of these two services, Entrectomy and other procedures performed on the same day for accurate reimbursement by the insurance or third-party payer.

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