Coding & Reimbursement

All About Modifier 78

By Suzanne L. Corcoran, COE

Modifier 78 is used to identify a return to the operating room for a related procedure during the surgical postoperative period. This article describes when its use is appropriate.

Q. How does CPT describe modifier 78?

A. Modifier 78 is defined in CPT as a return to the operating room for a related procedure during the postoperative period: “The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier ‘-78’ to the related procedure.”

Q. Would a minor surgery room located in a physicians office qualify as an operating room for this purpose?

A. No, although physicians occasionally do outfit surgical suites in their offices. The MCPM (Chapter 12, §40.1B) details what constitutes an operating room by stating: “An OR 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, an intensive care unit…”

Q. When is modifier 78 used?

A. Most related care provided to a patient in a global period following surgery is not separately billable. Modifier 78 is used to inform the payer of the unique circumstances and place of service (i.e., return to OR) that justifies separate reimbursement.

“Related care” is defined such that the problem or condition reported by the patient or identified by the surgeon is connected with the initial surgery. In general, the return to the OR within the postoperative period is medically necessary to address a complication resulting from the primary procedure.

Commonly, “related” refers to the operated eye. It might refer to an anatomical part of the operated eye or adjacent tissue that was affected by the initial surgery. For example, a “related” procedure could be a YAG laser capsulotomy in the global period following cataract surgery on the same eye, or a revision of a dehisced surgical incision following an eyelid procedure.

Q. Does modifier 78 have an impact on payment?

A. Yes. Related procedures provided during the global period of the initial procedure have concurrent postoperative days — the postoperative period is not extended. The allowed amount for claims submitted with modifier 78 is reduced by the value of the postoperative care for the related procedure; this value is 20% for almost all ophthalmology codes.

Q. How do payments for claims submitted with modifier 78 differ from those with the other surgical modifiers, 58 and 79?

A. Neither modifier 58 nor modifier 79 impacts the value of the claim when appended to a CPT code. A new global period begins with each procedure and payment is allowed in full. Modifier 58 is used for a staged or more-extensive related procedure performed in the postoperative period. Modifier 79 is added to claims for unrelated surgery.

An example of the appropriate use of modifier 58 might be a patient who develops endophthalmitis following cataract surgery and requires a vitrectomy. The vitrectomy is related to the recent cataract surgery and it is also a more extensive procedure than the initial procedure.

In addition, staged procedures require the use of modifier 58. Consider a patient who has a skin biopsy for a suspected cancer. Subsequently, the same surgeon performs a larger, deeper excision and reconstruction to remove the malignant lesion.

Use of modifier 79 is different. In ophthalmology, most patients have cataract surgery on both eyes within a short period of time, generally less than 90 days. The claim for the second cataract procedure is submitted with modifier 79. Both cataract procedures should be reimbursed in full.

Q. Is modifier 78 appropriate for repeat laser procedures performed within the global period?

A. CPT includes the phrase “one or more sessions” in the description for almost every ophthalmic laser procedure. This means that the surgeon receives just one payment even if the same laser treatment is repeated during the global period. Modifier 78 may not be used to circumvent this definition. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.