{"id":2359,"date":"2024-12-23T12:27:05","date_gmt":"2024-12-23T12:27:05","guid":{"rendered":"https:\/\/medibillmd.com\/blog\/?p=2359"},"modified":"2024-12-23T13:11:40","modified_gmt":"2024-12-23T13:11:40","slug":"modifier-78","status":"publish","type":"post","link":"https:\/\/medibillmd.com\/blog\/modifier-78\/","title":{"rendered":"Modifier 78 Description, Examples & Documentation Guidelines"},"content":{"rendered":"\n

Double the work and half the reimbursement? Are you missing out on your deserved dollars just because of modifier 78? Don\u2019t let the injustice continue. Find out all you need to know about this modifier, including its purpose, use cases, documentation requirements, dos and don\u2019ts, and distinguishing features. <\/p>\n\n\n\t\t\t\t

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  1. What is Modifier 78?<\/a>
  2. Modifier 78 Examples<\/a>
  3. Modifier 78 – Documentation Requirements<\/a>
  4. DOs and DON\u2019Ts for Appending Modifier 78<\/a>
  5. Modifier 78 vs 79<\/a>
  6. Summary<\/a><\/ol>\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\n\n\n
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    What is Modifier 78?<\/strong><\/h2>\n\n\n\n

    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. <\/p>\n\n\n\n

    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. <\/p>\n\n\n\n

    Modifier 78<\/strong> Examples<\/strong><\/h2>\n\n\n\n

    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\u2019s examples and use cases. Here are a couple of real-world applications of modifier 78.  <\/p>\n\n\n\n

    Treating a Post-Surgical Infection <\/strong><\/h3>\n\n\n\n

    Around 1-3%<\/a> 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.\u00a0<\/p>\n\n\n\n

    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. <\/p>\n\n\n\n

    Stopping Hemorrhage After Surgery<\/strong><\/h3>\n\n\n\n

    Postoperative hemorrhage or bleeding is another common complication after a surgical procedure, and 77.7%<\/a> 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%<\/a>. Therefore, it must be treated immediately.\u00a0<\/p>\n\n\n\n

    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.<\/p>\n\n\n\n

    Secondary Suturing of Abdominal Wall <\/strong><\/h3>\n\n\n\n

    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.  <\/p>\n\n\n\n

    Redoing a Vascular Bypass to Stop Leakage<\/strong><\/h3>\n\n\n\n

    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\u2019s 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.  <\/p>\n\n\n\n

    Modifier 78 – Documentation Requirements<\/strong><\/h2>\n\n\n\n

    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\u2019s documentation requirements usually include the following:<\/p>\n\n\n\n

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    • Physician\u2019s notes indicating the need for subsequent procedure<\/li>\n\n\n\n
    • Lab\/test reports for surgical complications<\/li>\n\n\n\n
    • Patient\u2019s medical history<\/li>\n\n\n\n
    • Patient\u2019s admission and discharge papers\u00a0<\/li>\n\n\n\n
    • Original referral letter for the initial surgery<\/li>\n<\/ul>\n\n\n\n

      DOs and DON\u2019Ts for Appending<\/strong> Modifier 78<\/strong><\/h2>\n\n\n\n

      Follow these dos and don\u2019ts to successfully append modifier 78 and capture accurate reimbursements for surgical procedures and services. <\/p>\n\n\n\n

      DOs<\/strong><\/h3>\n\n\n\n
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      1. Only use this modifier with surgical CPT and HCPCS codes.\u00a0<\/li>\n\n\n\n
      2. Append modifier 78 for the code that denotes the new but related surgical procedure (except when redoing a procedure).\u00a0<\/li>\n\n\n\n
      3. Include the new diagnosis code (e.g., \u201cinfection and inflammatory reaction due to internal left hip prosthesis, initial encounter\u201d) with the new procedural code for modifier 78 usage.\u00a0<\/li>\n\n\n\n
      4. Expect only a portion of the actual reimbursement for the new\/subsequent procedure. Typically, providers get up to 80% of the total cost.\u00a0<\/li>\n<\/ol>\n\n\n\n

        DON\u2019Ts  <\/strong><\/h3>\n\n\n\n
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        1. Don\u2019t use the modifier if the subsequent procedure\/service did not require returning to the operating room.\u00a0<\/li>\n\n\n\n
        2. Don\u2019t use modifier 78 if the same physician or another qualified healthcare professional did not perform the second procedure.<\/li>\n\n\n\n
        3. Don\u2019t append this modifier if the second surgical procedure was unrelated to the first one.\u00a0<\/li>\n\n\n\n
        4. Don\u2019t confuse modifier 78 with other postoperative modifiers 58 and 79.<\/li>\n<\/ol>\n\n\n\n

          Modifier 78 vs 79<\/strong><\/h2>\n\n\n\n

          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\u2019s distinguish between modifiers 78 and 79 to save you from mixing up the two. <\/p>\n\n\n\n

          <\/th>Modifier 78\u00a0<\/strong><\/th>Modifier 79<\/strong><\/th><\/tr><\/thead>
          Appended With  <\/strong><\/td>Surgical codes <\/td>Surgical codes <\/td><\/tr>
          Code Category<\/strong><\/td>Post-op<\/td>Post-op<\/td><\/tr>
          Subsequent Service Type <\/strong><\/td>Related to the first procedure<\/td>Unrelated to the first procedure<\/td><\/tr>
          Operating Physician <\/strong><\/td>Same physician or a qualified healthcare professional <\/td>Same physician or a physician from the same specialty <\/td><\/tr>
          Service Period<\/strong><\/td>Postoperative <\/td>Postoperative<\/td><\/tr>
          Second Procedure\u2019s Group<\/strong><\/td>Not necessarily from the same surgical group as the first procedure<\/td>The same surgical group as the first procedure<\/td><\/tr>
          Affect on the Global Period <\/strong><\/td>Does not reset<\/td>Resets<\/td><\/tr>
          Reimbursement Amount <\/strong><\/td>Up to 80%<\/td>100% <\/td><\/tr>
          Place of Service <\/strong><\/td>Operating Room (OR)<\/td>Operating Room (OR)<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

          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. <\/p>\n\n\n\n

          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. <\/p>\n\n\n\n

          Summary<\/strong><\/h2>\n\n\n\n

          In this comprehensive blog on modifier 78, we covered its standardized description, practical applications, documentation requirements, and dos and don\u2019ts while explaining how it is different from modifier 79, even though both are used for procedures performed in the postoperative period. <\/p>\n\n\n\n

          So, to summarize, you must append this modifier when the situation necessitates a patient\u2019s 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<\/strong><\/a> to a professional billing company like MediBillMD. Our AAPC-certified coders are proficient in the use of appropriate modifiers, guaranteeing accurate reimbursements.\u00a0<\/p>\n\n\n\n

          Frequently Asked Questions<\/strong><\/p>\n\n\n