Global Surgery Reimbursement Policy Concerning an Unplanned Return to the Operating Room; Modifier 78 will receive a 20% Fee Reduction*

Date Issued: 4/24/2015

Effective August 1, 2015, to further align with the Centers for Medicare and Medicaid Services (CMS), EmblemHealth will adopt the CMS reimbursement Policy for Modifier 78 for all Lines of Business.

Modifier 78 is used to report the unplanned return to the operating/procedure room by the same physician following an initial procedure for a related procedure during the postoperative period. 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 surgical procedure, and requires the use of the operating/procedure room, it may be reported by adding the Modifier 78 to the related procedure.

When Modifier 78 is appended to a procedure code having a Global Days Value of 010 or 090, EmblemHealth will reimburse only the intraoperative portion of the procedure reported, as determined by the intraoperative percentage listed on the CMS Medicare Physician Fee Schedule (MPFS). This will result in a proportionate payment reduction relative to the usual reimbursement under the global fee schedule. The global fee includes preoperative care subsequent to the decision for surgery, intraoperative services and typical postoperative follow-up care through the global period.

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 intraoperative services of the code that describes the treatment of the complications.

*The 20 % refers to a reduction of payment on claims submitted with modifier 78.

CMS link: