modifier 78

UHC Update to Global Surgery Reimbursement Policy

To further align with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare will adopt the CMS process for modifier 78 for Medicare Advantage plans effective April 1, 2015.
When modifier 78 is reported for a procedure having a Global Days Value of 010 or 090, UnitedHealthcare will reimburse only for the intraoperative percentage of the modified procedure, determined by the intraoperative percentage listed on the CMS Medicare Physician Fee Schedule (MPFS). This will result in payment reductions accordingly.
According to the CMS Medicare Claims Processing Manual, Chapter 12, Section 40.4C: “When a CPT code billed with modifier ‘-78’ describes the services involving a return trip to the operating room to deal with complications, pay the value of the intra-operative services of the code that describes the treatment of the complications. Refer to Field 18 of the MPFS to determine the percentage of the global package for the intra-operative services.”


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