Modifier 78 — Unplanned Return to the Operating Room during Post-Operative Period
Defines when Premera recognizes Modifier 78 on professional claims (CMS-1500/837P) for unplanned returns to the OR by the same physician for related procedures during the global period and the reimbursement adjustment that applies; applies to Premera Blue Cross, Premera BCBS of Alaska, LifeWise Health Plan of Washington, LifeWise Assurance Company, and Premera Blue Cross HMO lines of business.
Removed references to modifier 76 for an unplanned return to the OR for a repeat of the same original surgical procedure in the global period of the original surgery.
Removed an exception specific to Oregon that reimbursed 100% of the provider's applicable fee schedule allowed amount.
Added link to the CMS National Physician Fee Schedule and identified the 'Global Days' column as the source for procedure global periods.
Clarified that the policy pertains to professional services billed on CMS-1500 or 837P claim forms.
When Modifier 78 Is Recognized
When Modifier 78 is recognized
Conditions that must be met for the plan to recognize Modifier 78 on a professional claim.
ALL of the following
- Service is a professional service billed on CMS-1500 or 837P.
- Return to the operating room was unplanned during the global period of the initial procedure.
- Return is for a related procedure or treatment of complications requiring return to the operating room.
- Return is performed by the same physician or other qualified healthcare professional who performed the initial procedure.
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