Coding & Reimbursement

The Change That Keeps on Confusing

By Suzanne L. Corcoran, COE

The American Medical Association, creator of the CPT Handbook, occasionally changes definitions in the book. In 2008, the definition of modifier 78 was changed, and this alteration is still creating questions for practices, even four years later. I hope the answers I provide here will clear up some of the confusion.

Q What is the CPT definition of modifier 78, and how has it changed?

A Modifier 78 is defined in CPT as: “Unplanned return to the operating/procedure room … It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure.”

What changed is the reference to “an operating/procedure room.” Prior to this change, the definition referenced only an operating room. And, although the CPT description changed, many payers have not changed their policies.

Q Would a minor procedure room located in the physician's office qualify as an operating room for this purpose?

A Not by Medicare's definition. The Medicare Claims Processing Manual (MCPM) Chapter 12 §40.1B defines an operating room (OR) as: “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 …”

Some ophthalmology practices have fully equipped operating rooms, although this is rare. Many offices have a laser suite that can qualify as an OR.

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.

Use modifier 78 when the same physician performs the second, related procedure. Note that Medicare considers all physicians of the same specialty within the same group practice to be the “same physician,” so modifier 78 would also apply when another ophthalmologist in the group performs the second (related) procedure.

Q Define “related” in this context.

A The problem or condition reported by the patient or identified by the surgeon is connected with the initial surgery in some way. In general, the return to the OR within the global surgery 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 affect 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 to the intraoperative value of the related procedure. This is 70% for most ophthalmic procedures.

Q Is modifier 78 used with minor surgical procedures?

A Rarely. Modifier 78 requires a return to an OR in the global period. Minor surgery rarely needs to be done in an operating room. By comparison, modifiers 58 and 79 do not require an OR and may be used with claims for minor surgeries.

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 most ophthalmic lasers. This means that the surgeon receives just one payment even if the same laser treatment is repeated during the postoperative period. Modifier 78 may not be used to circumvent this definition. The “one or more sessions” rule applies to professional services, but not to facility fees. OM

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