Palmetto GBA: , CPT Modifier 78
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Description:
Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postoperative period

Guidelines/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.
  • This modifier may only be submitted with surgery codes
  • An operating room 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 or an intensive care unit unless the patient's condition was so critical there would be insufficient time for transportation to an operating room.
  • No additional documentation is required with the claim. Supporting documentation must be maintained in the patient's medical record. The documentation must substantiate that the surgeries are related and that the subsequent surgery required a return to the O/R.
  • If the subsequent surgery is unrelated to the initial surgery and both are performed by the same surgeon, refer to CPT modifier 79
  • If the subsequent surgery is related to the initial surgery but does not require a return to the operating room, and both are performed by the same surgeon, the subsequent surgery cannot be submitted separately. The global fee for the initial surgery includes additional related surgical procedures that do not require a return to the operating room.
  • E/M services on the same day as a procedure with 0 or 10 global days are generally not payable separately from the procedure. For additional information, please refer to CPT modifier 25
  • E/M services on the day of the procedure and during this 10-day postoperative period are generally not payable. For additional information, please refer to CPT modifier 57.
  • If a (subsequent) bilateral procedure requires a return to the operating room after the initial surgery and the Bilateral Indicator in the MPFSDB is 1 or, do not submit CPT modifier 50. CPT modifiers 50 and 78 cannot be submitted for the same service. Instead, submit the surgery procedure code with CPT modifier 78 and HCPCS modifier RT on one detail line, and submit the same surgery procedure code with CPT modifier 78 and HCPCS modifier LT on a separate detail line.

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.

Payment:

  • Procedure codes that have 10 or 90 global days on the MPFSDB are paid at the intra-operative percentage displayed on the MPFSDB. The procedure's fee schedule amount is multiplied by the percentage and rounded to the nearest cent.
  • Procedure codes that have 0 global days on the MPFSDB are paid at the full fee schedule amount.

To determine the global period of a surgery, refer to the Medicare Physician Fee Schedule database (MPFSDB).

  • Access the database directly from the CMS Web site at www.cms.gov/PFSlookup/
  • Select Physician Fee Schedule Search from the left area of the Web page
  • Screen defaults to current year. Under Type of Information, select Payment Policy Indicators, then 'next'
  • On the 'select field options' screen, select 'Next'
  • Enter the procedure code and select 'All Modifiers', then click 'Submit'
  • Refer to the column heading 'Global'
  • 000 = Endoscopic or minor procedure with related preoperative and postoperative relative value units on the day of the procedure only, included in the fee schedule payment amount
  • 010 = Minor procedure with preoperative relative values on the day of the procedure and postoperative values during a 10-day postoperative period included in the fee schedule amount
  • 090 = Major surgery with a one-day preoperative period and 90-day postoperative period included in the fee schedule payment amount
  • MMM = Maternity codes. The usual global period does not apply.
  • XXX = Global concept does not apply. YYY = Palmetto GBA will determine whether the global concept applies and establish a postoperative period if appropriate.
  • ZZZ = Code is related to another service ('add-on' code) and is always included in the global period of the other service

Examples for Correct Submission of CPT Modifier 78
Example 1:
A colon resection (CPT code 44143) was performed on May 26, 2009. Complications occurred on the same date, and the patient was returned to the O/R 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, 2009. On June 30, 2009, within the post-op period of the cataract removal surgery, a YAG laser capsulotomy (CPT code 66821) was performed on the right eye. The outcome is to submit CPT modifier 78 with CPT code 66821 since this procedure is related to the prior surgery.

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