CurrentAmerigroupPolicy G-13001

Reimbursement Policy Modifier 78

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Defines when Amerigroup will reimburse claims billed with CPT modifier 78 for unplanned returns to the operating or procedure room during the postoperative period and how reimbursement is calculated; applies to providers submitting claims to Amerigroup per contract and regulatory requirements.

Policy Summary

PayerAmerigroup

PolicyReimbursement Policy Modifier 78

Policy CodePolicy G-13001

Change TypeOperational and Administrative

Effective DateSep 11, 2025

Last ReviewSep 11, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; services may require authorization per member benefit.

SourceLink

POLICY UPDATE CHANGES

Added 'Global Surgical Package' to the Related Policies and Materials section.

Removed 'Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period' from the policy title.

70%reimbursement rate when modifier 78 is valid

multiplerelated policies listed

Reimbursement Criteria for Modifier 78

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CurrentAmerigroupPolicy G-13001

Reimbursement Policy Modifier 78

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Get alerted when Policy G-13001 changes without checking for updates manually.

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Policy Summary

PayerAmerigroup

PolicyReimbursement Policy Modifier 78

Policy CodePolicy G-13001

Change TypeOperational and Administrative

Effective DateSep 11, 2025

Last ReviewSep 11, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; services may require authorization per member benefit.

SourceLink

POLICY UPDATE CHANGES

Added 'Global Surgical Package' to the Related Policies and Materials section.

Removed 'Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period' from the policy title.

70%reimbursement rate when modifier 78 is valid

multiplerelated policies listed

Reimbursement Criteria for Modifier 78

Reimbursement criteria for Modifier 78

Covered when ALL of the following are met:

ALL of the following

The return to the operating or procedure room is unplanned
The procedure appended with modifier 78 is the appropriate surgical code for the procedure performed
The procedure is performed by the same physician who provided the initial procedure
The procedure is related to the initial procedure
The procedure is performed during the postoperative period of the initial procedure
Reimbursement is based on the surgical procedure only (preoperative and postoperative care are excluded)
Exclusions
- Modifier 78 is not reimbursed when billed with non-surgical codes
- Modifier 78 is not reimbursed with codes whose description denotes subsequent, related, or redo

ALL of the following

When valid, reimbursement for the surgical procedure billed with modifier 78 is 70% of the fee schedule or the contracted/negotiated rate
When an assistant surgeon is used during the same operative session in the global period, assistant surgeon rules apply

ALL of the following

Services must meet authorization and medical necessity requirements appropriate to the procedure and diagnosis; services may require authorization per member benefit

Modifier and Reimbursement Rate

ModifierModifierCovered

Modifier 78

Indicates a subsequent procedure performed during the postoperative period that is related to the original procedure and requires return to the operating/procedure room.

Reimbursement when modifier 78 is valid

Reimbursement rate70% of the fee schedule or the contracted/negotiated rate when modifier 78 is valid

Scope of reimbursementBased on the surgical procedure only — preoperative and postoperative care are excluded

ApplicabilityApplies when criteria for modifier 78 are met (unplanned return, same physician, related procedure, performed during postoperative period)

Contract and regulatory exceptionsNot reimbursed if provider, state, federal, or CMS contracts/requirements indicate otherwise

Global package exclusionProcedures during the postoperative period not billed with modifier 78 are normally not eligible for reimbursement as they are included in the global surgical package

Authorization and Medical Necessity

Prior Authorization

Authorization and medical necessity — confirm prior authorization and documentation

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; services may require authorization per the member benefit. Use proper billing and submission guidelines and ensure services billed are fully supported in the medical record and/or office notes. Failure to follow coding/billing guidelines or reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement to reflect appropriate services performed.

Verify member benefit authorization requirements before performing the procedure.
Document clinical justification and operative details in the medical record to support use of modifier 78.
Follow industry-standard CPT/HCPCS/revenue code billing and submission guidelines to avoid denials or recoupment.

Modifier Definitions

Modifier 78 — definition and requirements

DefinitionModifier 78: Indicates a subsequent procedure performed during the postoperative period of the original surgical procedure that is related to the original procedure and requires a return to the operating/procedure room.

Relation requirementSubsequent procedure must be related to the original procedure

Location requirementMust require a return trip to the operating or procedure room

Timing requirementProcedure must occur during the postoperative period of the initial procedure

Coding noteProcedure appended with modifier 78 must be the appropriate surgical code and performed by the same physician who provided the initial procedure

Policy Summary

PayerAmerigroup

PolicyReimbursement Policy Modifier 78

Policy CodePolicy G-13001

Change TypeOperational and Administrative

Effective DateSep 11, 2025

Last ReviewSep 11, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; services may require authorization per member benefit.

SourceLink

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