CurrentBlue Cross Blue Shield - MainePolicy G-13001

Modifier 78

This reimbursement policy governs when Modifier 78 may be billed and reimbursed for unplanned returns to the operating or procedure room related to an initial surgery during the postoperative period for Anthem Blue Cross and Blue Shield members (including Maine). It affects providers submitting claims for surgical services.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier 78

Policy CodePolicy G-13001

Change TypeReimbursement methodology revisedrelated materials updated

Effective DateSep 11, 2025

Next Review Date

Key ActionEnsure claims with Modifier 78 meet authorization and medical necessity guidelines and follow proper billing and submission procedures.

SourceLink

POLICY UPDATE CHANGES

Reimbursement methodology changed to 'based on 70% of the fee schedule or contracted/negotiated rate'.

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

Policy title wording was changed by removing a longer descriptive phrase about unplanned return to the operating/procedure room.

70%reimbursement rate for valid Modifier 78 services

1-2 sentencedefinition of Modifier 78 provided

Multiplepolicy history items (2015-2025)

Modifier 78 Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier 78

Policy CodePolicy G-13001

Change TypeReimbursement methodology revisedrelated materials updated

Effective DateSep 11, 2025

Next Review Date

Key ActionEnsure claims with Modifier 78 meet authorization and medical necessity guidelines and follow proper billing and submission procedures.

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.

ALL of the following

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 subsequent procedure is related to the initial procedure.
The procedure is performed during the postoperative period of the initial procedure.
Reimbursement is based on 70% of the fee schedule or the contracted/negotiated rate and applies to the surgical procedure only (preoperative and postoperative care included in the global package are not separately reimbursed).

Nonreimbursable circumstances

When billed with non-surgical codes.
When billed with codes that denote subsequent, related, or redo in the description.

Billing notes

Procedures rendered during the postoperative period and not billed with modifier 78 are normally not eligible for separate reimbursement as they are included in the global surgical package.
When an assistant surgeon is used during the global period in the same operative session, assistant surgeon rules apply.

Coding and Reimbursement

Modifier 78ModifierCovered

Modifier 78

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

Modifier 78 - Nonreimbursable UsesModifierNot Covered

Modifier 78

Not reimbursable when billed with non-surgical codes or with codes denoting subsequent, related, or redo in the description.

Reimbursement factor — Modifier 78

Reimbursement factor70% of the fee schedule or the contracted/negotiated rate of the surgical procedure code when the modifier is valid for the service performed

Applies to surgical procedure onlyReimbursement is based on the surgical procedure only and does not include preoperative or postoperative care included in the global package

Subject to contracts and requirementsPayment applies unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise

Condition of validityModifier must be valid for the service performed (i.e., criteria for Modifier 78 are met)

Authorization and Billing Guidance

Prior Authorization

Prior Authorization and Billing Requirements

Prior authorization may be required and claims must be billed with appropriate, supported coding and documentation. Verify member benefits and obtain any required prior authorization before scheduling services. Ensure the medical record and office notes fully support the billed CPT/HCPCS/revenue codes, diagnosis(es), and medical necessity. Retain documentation of clinical indication, treatment plan, and any prior-authorization approval or denial for audit.

Verify member eligibility and benefits and obtain prior authorization when required • Keep prior-authorization approval number with the patient record.
Bill services using industry-standard CPT, HCPCS, and revenue codes that accurately describe the service provided.
Ensure documentation supports coding and medical necessity (clinical notes, diagnostic tests, and treatment rationale).
If coding/billing guidelines are not followed, the claim may be rejected, denied, adjusted, or payment may be recouped.
Follow applicable state, federal, and CMS requirements which may supersede this policy.

Key Definitions

Modifier 78 — definition

DefinitionUsed to indicate that a subsequent procedure was performed during the postoperative period of the original surgical procedure; the subsequent procedure must be related to the original procedure and must require a return trip to the operating or procedure room

Relationship requirementThe subsequent procedure must be related to the initial procedure

Location requirementProcedure must require a return to the operating or procedure room

Timing requirementProcedure must be performed during the postoperative period of the original surgical procedure