CurrentAnthemPolicy G-13001

Modifier 78

Defines Anthem Blue Cross Medi-Cal Managed Care reimbursement rules for services billed with CPT/HCPCS modifier 78 (return to operating/procedure room) for providers in California.

Policy Summary

PayerAnthem Blue Cross (Medi‑Cal)

PolicyModifier 78 reimbursement

Policy CodePolicy G-13001

Change TypeAdministrative (related policies list updated)

Effective DateSep 11, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and include proper billing, submission, and supporting documentation when billing with modifier 78.

SourceLink

POLICY UPDATE CHANGES

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

70%Reimbursement rate

CaliforniaState

Modifier 78Subject

Non-surgical codesExclusions example

Modifier 78 Coverage Criteria

Modifier 78 coverage criteria

Reimbursement allowed when ALL of the following criteria 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
Performed by the same physician who provided the initial procedure
Procedure is related to the initial procedure
Performed during the postoperative period of the initial procedure

Policy Summary

PayerAnthem Blue Cross (Medi‑Cal)

PolicyModifier 78 reimbursement

Policy CodePolicy G-13001

Change TypeAdministrative (related policies list updated)

Effective DateSep 11, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and include proper billing, submission, and supporting documentation when billing with modifier 78.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Modifier and Reimbursement Basis

Modifier 78ModifierCovered

Modifier 78

Subsequent procedure during the postoperative period requiring return to the operating/procedure room; must be related to original procedure and by same physician.

Reimbursement basis

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

Scope of paymentReimbursement applies to the surgical procedure only; preoperative and postoperative care are excluded

Condition for applicabilityModifier 78 must be valid for the service billed (unplanned return to the operating/procedure room related to initial procedure by same physician during postoperative period)

Contract/requirement precedenceNo reimbursement if provider, state, federal, or CMS contracts/requirements indicate otherwise

Global package impactProcedures 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, Documentation, and Prior Authorization

Prior Authorization

Prior Authorization Applicability

Prior Authorization Required: Prior authorization may be required when a return to the operating or procedure room is NOT unplanned or when plan, state, federal, or CMS contracts/requirements specify prior authorization. Verify member benefits and authorization requirements before performing planned re-operations or procedures during a global/postoperative period.

Prior auth applicability varies by contract, state, and federal/CMS mandates
Planned returns to the OR (not unplanned) generally require prior authorization
When in doubt, obtain prior authorization prior to the procedure to avoid claim denial or recoupment

Documentation Required

Authorization and Documentation Requirements

Documentation and Billing Requirements: The return-to-OR service must be clearly documented as unplanned, performed by the same physician, related to the initial procedure, and performed during the initial procedure's postoperative period. Use the appropriate surgical CPT code for the procedure performed and append modifier 78 when criteria are met. Support all billed services with contemporaneous medical record documentation (operative notes, rationale for return, timing relative to index procedure, and indication that care was for the same diagnosis).

Reimbursement for valid modifier 78 claims is 70% of the fee schedule or contracted rate for the surgical procedure code
Modifier 78 reimbursement covers the surgical procedure only; preoperative and postoperative care are not separately reimbursed
Procedures during the postoperative period not billed with modifier 78 are typically considered included in the global surgical package and may be denied
If an assistant surgeon is used in the same operative session during the global period, assistant surgeon billing rules apply
Failure to follow coding/billing guidelines or provide documentation may result in claim rejection, denial, or recovery/recoupment

Key Definitions

Modifier 78 — definition and scope

PurposeIndicates a subsequent procedure performed during the postoperative period of the original surgical procedure

Relationship requirementThe subsequent procedure must be related to the original procedure

Location requirementThe subsequent procedure must require a return trip to the operating or procedure room

Provider requirementModifier 78 applies when the subsequent procedure is performed by the same physician who provided the initial procedure (per policy criteria)

Timing requirementUsed only for procedures performed during the postoperative period of the initial procedure