-78 Unplanned Return to the Operating/Procedure Room by the Same Physician
Defines appropriate and inappropriate use and reimbursement rules for billing modifier -78 for UCare products, including Medicare Advantage, MHCP, and commercial products. Affects providers billing related unplanned procedures during the postoperative/global period.
No material clinical or coverage changes in this revision.
Coverage and Payment Criteria for Modifier -78
Modifier -78 coverage criteria
Coverage and payment rules when modifier -78 is appended:
Product-specific payment rules
- UCare Medicare Advantage, Dually Integrated programs when Medicare is primary, and UCare Commercial products: allowed amount based on the intra-operative percentage listed in the 'INTRA OP' field of the CMS MPFSRVF for services with a 90- or 10-day global period.
- MHCP (when MHCP is primary): payment made at 76% of the base allowed amount when -78 is appended to an eligible service.
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