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Unplanned Return to Surgery
Description
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.
Per CMS and CPT, modifier 78 should be reported with procedure codes for treatment of postoperative complications that require a return trip to the operating room.
Policy
Blue Cross Blue Shield North Carolina (Blue Cross NC) will reduce payment by 30% for unplanned return to surgery services, as indicated by modifier 78.
Reimbursement Guidelines
Services submitted with a 78 modifier will receive 70% of the allowed reimbursement.
A 78 modifier payment reduction will apply to any service with a 10- or 90-day global period containing an intraoperative percentage, per the Medicare physician fee schedule.
Modifier 78 may only be submitted with surgical codes.
Modifier 78 may not be submitted with modifier 80-82. Submit these claims with the appropriate assistant-atsurgery CPT modifier (80-82) only.
A new global period will not be initiated with the return trip to surgery, as indicated with 78 modifier.
Rationale
In alignment with CMS and correct coding initiatives, Blue Cross NC will reduce reimbursement for services filed with modifier 78.
Billing and Coding
Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.
| Modifier | Description |
|---|---|
| Modifier 78 | 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. |
Related policy
Modifier Guidelines
References
American Medical Association, Current Procedural Terminology (CPT® )
CMS Medicare Claims Processing CMS Pub 100-04
History
| Date | Description |
|---|---|
| 10/19/2021 | New policy developed. Blue Cross NC will reduce payment by 30% for unplanned return to surgery services, as indicated by modifier 78. Notification on 10/19/2021 for effective date 1/1/2022. (eel) |
| 12/31/2022 | Routine policy review. Minor revisions only. (ckb) |
Application
These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.
This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore, member benefit language should be reviewed before applying the terms of this policy.
Disclosures:
Reimbursement policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and Blue Cross NC reserves the right to review and revise its medical and reimbursement policies periodically.
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