CurrentAnthemPolicy G-13001

Modifier 78

Defines Anthem New York Medicaid reimbursement rules for billing Modifier 78 when a patient has an unplanned return to the operating or procedure room during the postoperative period. Applies to claims submitted to Anthem Blue Cross and Blue Shield HP for New York Medicaid.

Policy Summary

PayerAnthem

PolicyModifier 78

Policy CodePolicy G-13001

Change TypeTitle revision; related policies updated

Effective DateSep 11, 2025

Next Review Date

Key ActionBill the appropriate surgical code and append modifier 78 only when all criteria are met and documentation supports an unplanned, related return to the operating/procedure room performed by the same physician during the postoperative period.

SourceLink

POLICY UPDATE CHANGES

Updated Related Policies and Materials section to include 'Global Surgical Package'.

Policy title was changed on 09/27/2023 by removing a longer descriptive title.

100%maximum allowed reimbursement of surgical procedure when modifier 78 is valid

Reimbursement Conditions for Modifier 78

Conditions required for reimbursement with modifier 78

All of the following must be met to allow reimbursement when billing modifier 78:

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.

Policy Summary

PayerAnthem

PolicyModifier 78

Policy CodePolicy G-13001

Change TypeTitle revision; related policies updated

Effective DateSep 11, 2025

Next Review Date

SourceLink

On This Page

Billing, Documentation, and Reimbursement Rules

Billing Rule

Billing requirements for Modifier 78

Bill the appropriate surgical CPT/HCPCS code for the procedure performed and append Modifier 78 only when all policy criteria are met; do not bill Modifier 78 with nonsurgical codes or with codes whose description denotes subsequent/related/redo. Ensure the service is billed by the same physician who performed the original procedure and that the procedure occurred during the postoperative period.

Modifier: 78

Documentation Required

Documentation support

Medical record and operative notes must document that the return was unplanned, that the procedure was related to the initial procedure, occurred during the postoperative period, and was performed by the same physician; services must be supported in the records to justify modifier use.

Billing Rule

Reimbursement applies to surgical procedure only

Reimbursement is for the surgical procedure only and does not include preoperative or postoperative care; procedures during the postoperative period that are not billed with Modifier 78 are normally considered included in the global surgical package.

Maximum reimbursement will not exceed 100% of the maximum fee schedule or contracted/negotiated rate of the surgical procedure code when Modifier 78 is valid.

Billing Rule

Assistant surgeon during global period

When an assistant surgeon is used during the global period in the same operative session, assistant surgeon rules apply and should be followed for payment determination.

Policy Scope and Context

Defines Anthem New York Medicaid reimbursement rules for billing Modifier 78 when a patient has an unplanned return to the operating or procedure room during the postoperative period. Applies to claims submitted to Anthem Blue Cross and Blue Shield HP for New York Medicaid and is effective 09/11/2025.

The policy allows reimbursement for claims billed with Modifier 78 only when all of the following are met: 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; and the procedure is performed during the postoperative period of the initial procedure.

Reimbursement for a valid use of Modifier 78 is limited to the surgical procedure only and will not exceed 100% of the maximum fee schedule or contracted/negotiated rate for the surgical procedure code. Preoperative and postoperative care are not separately reimbursed when the procedure is part of the global surgical package, and procedures during the postoperative period that are not billed with modifier 78 are typically considered included in the global surgical package.

Modifier 78 is not reimbursable when billed with nonsurgical codes or with codes whose descriptions denote subsequent, related, or redo procedures. When an assistant surgeon is used during the global period in the same operative session, assistant surgeon rules apply.

Medical record and operative notes must support that the return was unplanned, related to the initial procedure, occurred during the postoperative period, and was performed by the same physician; services must be documented to justify modifier use. Refer to related policies such as Global Surgical Package, Modifier Usage, and assistant/other modifier policies for additional guidance.

OpenPayer

Modifier 78

Reimbursement Conditions for Modifier 78

Codes and Billing Category

Billing, Documentation, and Reimbursement Rules

Policy Scope and Context

Defined Terms

Policy Updates

Modifier 78

Reimbursement Conditions for Modifier 78

Codes and Billing Category

Billing, Documentation, and Reimbursement Rules

Policy Scope and Context

Defined Terms

Policies to Read With This Policy

Policy Updates