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Printed Date: 9/22/2015
Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period.
Guidelines and Instructions
Submit this modifier to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure) when the subsequent procedure is related to the first and requires the use of an operating or procedure room.
Do not submit this modifier with assistant surgery services because global surgery rules do not apply to assistants. Services submitted with CPT modifier 80-82 in addition to CPT modifier 78 will be "returned as unprocessable" (rejected with remark code MA130). Resubmit these claims with the appropriate assistant-at-surgery CPT modifier (80-82) only.
To determine the global period of a surgery, refer to the MPFSDB.
Examples for Correct Submission of CPT Modifier 78
Example 1: A colon resection (CPT code 44143) was performed on May 26. Complications occurred on the same date, and the patient was returned to the Operating Room to reopen the abdomen (CPT code 49002) to control bleeding. The outcome is to submit CPT modifier 78 with CPT code 49002.
Example 2: Right cataract extraction (CPT code 66984) was performed on May 1. On June 30, within the post-op period of the cataract removal surgery, a YAG laser capsulotomy (CPT code 66821) was performed on the right eye. Submit CPT modifier 78 with CPT code 66821 since this procedure is related to the prior surgery.
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Last Updated: 07/16/2020