Modifier 78 Description, Examples & Documentation Guidelines

Double the work and half the reimbursement? Are you missing out on your deserved dollars just because of modifier 78? Don’t let the injustice continue. Find out all you need to know about this modifier, including its purpose, use cases, documentation requirements, dos and don’ts, and distinguishing features.

Table Of Contents

What is Modifier 78?
Modifier 78 Examples
Modifier 78 – Documentation Requirements
DOs and DON’Ts for Appending Modifier 78
Modifier 78 vs 79
Summary

What is Modifier 78?

Modifier 78 is used when the healthcare provider wants to bill the insurance payer for an unplanned return to the operating room following a surgical procedure. The same provider or another qualified healthcare professional may operate on the same patient to address the complications that arose after the initial procedure during the postoperative period. That is why modifier 78 is known as a post-op modifier and part of a set of three: Post-op modifiers 58, 78, and 79.

Note that the global surgery period or postoperative period lasts between 0, 10, and 90 days, depending on whether the surgery was minor or major. Moreover, applying the CPT modifier 78 will not reset the global surgery period. Hence, providers should not expect 100% reimbursement for the related procedure if it was performed within 90 days of the initial surgery.

Modifier 78 Examples

You must understand that incorrectly appending modifier 78 with surgical codes will result in claim denials, as the insurance payers may get the impression that you are trying to upcode a procedure for higher reimbursements. Therefore, it is vital for you to be familiar with modifier 78’s examples and use cases. Here are a couple of real-world applications of modifier 78.

Treating a Post-Surgical Infection

Around 1-3% of the patients who undergo surgery develop surgical site infections (SSI) due to bacterial contamination. Most of these infections occur within 30 days of the surgery (or in the postoperative period). Usually, these infections can be treated with antibiotics and proper wound care.

However, sometimes, the surgeon may have to perform another surgery to treat the infection, such as pus infections in organs and tissues. Therefore, modifier 78 will be appended with the new surgical code for appropriate global surgery package reimbursement.

Stopping Hemorrhage After Surgery

Postoperative hemorrhage or bleeding is another common complication after a surgical procedure, and 77.7% of these incidents occur within 7 days of the surgery. Its causes include faulty stitches or staples, injury to other organs during surgery, or failure to secure blood vessels. The mortality rate from postoperative hemorrhage is up to 38%. Therefore, it must be treated immediately.

So, if the patient was taken to the operating room again for surgical intervention for postoperative bleeding or blood transfusion, modifier 78 will be appended to explain this.

Secondary Suturing of Abdominal Wall

Evisceration, or the protrusion of internal organs through a wound, is sometimes experienced after abdominal surgeries. It is a medical emergency that must be immediately treated to prevent fatalities. The surgeon arranges for the patient to be back in the operating room for surgical repair or repositioning of the organs and secondary suturing of the abdominal wall to seal open wounds. Hence, modifier 78 is appended to explain this related and subsequent surgical procedure within the postoperative period.

Redoing a Vascular Bypass to Stop Leakage

Suppose a patient with gangrenous toes underwent vascular bypass surgery to reroute the blood flow around a blocked artery on May 1. After 14 days, the graft starts leaking, causing a serious medical emergency that must be immediately dealt with. The physician arranges the patient’s return to the operating room on May 15 to redo the bypass and repair the leak. In this case, he will append modifier 78 with the surgical CPT code 35656 (femoral artery bypass with synthetic graft) for accurate reimbursement.

Modifier 78 – Documentation Requirements

All the supporting documents submitted to the insurance payer with the claim form must prove the medical necessity for the related surgical procedure to justify using modifier 78. So, modifier 78’s documentation requirements usually include the following:

Physician’s notes indicating the need for subsequent procedure
Lab/test reports for surgical complications
Patient’s medical history
Patient’s admission and discharge papers
Original referral letter for the initial surgery

DOs and DON’Ts for Appending Modifier 78

Follow these dos and don’ts to successfully append modifier 78 and capture accurate reimbursements for surgical procedures and services.

DOs

Only use this modifier with surgical CPT and HCPCS codes.
Append modifier 78 for the code that denotes the new but related surgical procedure (except when redoing a procedure).
Include the new diagnosis code (e.g., “infection and inflammatory reaction due to internal left hip prosthesis, initial encounter”) with the new procedural code for modifier 78 usage.
Expect only a portion of the actual reimbursement for the new/subsequent procedure. Typically, providers get up to 80% of the total cost.

DON’Ts

Don’t use the modifier if the subsequent procedure/service did not require returning to the operating room.
Don’t use modifier 78 if the same physician or another qualified healthcare professional did not perform the second procedure.
Don’t append this modifier if the second surgical procedure was unrelated to the first one.
Don’t confuse modifier 78 with other postoperative modifiers 58 and 79.

Modifier 78 vs 79

Modifiers 78 and 79 are both used to indicate a procedure or service that was performed in the postoperative period. However, their complete descriptions and real-world applications are different. Let’s distinguish between modifiers 78 and 79 to save you from mixing up the two.

	Modifier 78	Modifier 79
Appended With	Surgical codes	Surgical codes
Code Category	Post-op	Post-op
Subsequent Service Type	Related to the first procedure	Unrelated to the first procedure
Operating Physician	Same physician or a qualified healthcare professional	Same physician or a physician from the same specialty
Service Period	Postoperative	Postoperative
Second Procedure’s Group	Not necessarily from the same surgical group as the first procedure	The same surgical group as the first procedure
Affect on the Global Period	Does not reset	Resets
Reimbursement Amount	Up to 80%	100%
Place of Service	Operating Room (OR)	Operating Room (OR)

From the table above, we can see that modifiers 78 and 79 have distinct purposes, requirements, and effects on the final reimbursement. While modifier 78 explains an unplanned return to the operating room to treat a complication or condition that results from the first surgery during the postoperative period, modifier 79 indicates an unrelated procedure within 90 days of the initial surgery.

Since the two surgeries are separate and unrelated in the case of modifier 79, it starts a new global period, causing the payer to reimburse the second surgery completely.

Summary

In this comprehensive blog on modifier 78, we covered its standardized description, practical applications, documentation requirements, and dos and don’ts while explaining how it is different from modifier 79, even though both are used for procedures performed in the postoperative period.

So, to summarize, you must append this modifier when the situation necessitates a patient’s unplanned return to the operating room (within the global surgery period) for a related procedure, e.g., to treat a medical complication or condition that resulted from the initial surgery. However, if you are still confused and frequently encounter modifier 78-related denials, outsource medical coding to a professional billing company like MediBill MD. Our AAPC-certified coders are proficient in the use of appropriate modifiers, guaranteeing accurate reimbursements.

Frequently Asked Questions

What is an example of a modifier 78?

Modifier 78 examples include medical complications that arise after surgery, such as internal bleeding, bacterial infections, and eviscerations, necessitating performing another procedure or redoing the previous one.

Does modifier 78 reduce payment?

Yes. Providers get a reduced payment for the second procedure because it is related to the first one and covered by the global surgical package. Usually, providers receive up to 80% of the actual reimbursement rate.

Can modifier 78 be used in an office setting?

No. This modifier cannot be used for a procedure performed in an office setting. The patient and physician must return to the operating room for the modifier to be valid.

What is the difference between modifiers 78 and 76?

The underlying difference between modifiers 78 and 76 is that while 78 indicates the physician’s unplanned return to the operating room for a related procedure after the initial surgery, 76 explains that the same procedure or service was repeated by the same physician on the same day or within the postoperative period. Hence, while 78 is appended with a new surgical CPT code, the CPT code for modifier 76 remains the same as the first procedure.

Can you use modifiers 78 and 58 together?

No. Modifiers 78 and 58 are mutually exclusive post-op modifiers and cannot be used together. You can append only the most appropriate one to claim reimbursement for a related procedure during the global surgery period.

Does modifier 78 restart the global period?

No. This modifier does not reset the global surgery period because the second procedure is related to the first one and is covered under the global surgical package.

What is the CMS guideline for modifier 78?

The Centers for Medicare and Medicaid Services (CMS) requires the provider to submit proof of medical necessity to justify using this modifier with the new CPT code for the subsequent procedure. Therefore, the provider must use the correct diagnostic and procedural codes and submit the patient’s complete medical record, including physician notes and lab reports, as supporting documents.

Which modifier goes first, 78 or 59?

When using modifiers 78 and 59 together, always report 78 before 59. Modifier 78 is a pricing modifier, whereas modifier 59 is a payment modifier and appended for distinct and separate procedures or services. As per the rule of thumb, pricing modifiers are followed by payment modifiers and payment modifiers are followed by location modifiers.

Can modifier 78 be used in POS 11?

No. This post-op surgical modifier cannot be used with the Place of Service (POS) code 11 because the second procedure must also be performed in an operating room. POS 11 is used for office settings.

Can ASC use modifier 78?

No. Ambulatory Surgical Centers (ASCs) should not use this modifier because their global surgery period is the same day as the date of service. So, they cannot claim reimbursement for a subsequent and related procedure within the 10- or 90-day postoperative period. Moreover, ASCs file claims for facility charges and not for physician’s fees.