Orthopedic Coding Alert

Question: I-ve noticed that when we report procedures with modifier 78, the payer will reduce our fee. Is this appropriate, or should I be appealing these claims?

Tennessee Subscriber

Answer: When you file claims with modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period), you should not expect to receive the full fee schedule reimbursement.

Procedures billed with modifier 78 include only the "intraoperative" portion of the service (no payment is made for pre- and postoperative care). They are generally reimbursed at 65-80 percent of the full fee schedule value, depending on how the fee schedule allocates the presurgical, intraoperative, and postsurgical portions of the reimbursement for a particular CPT code.

Note, however, that the global period is not reset when you submit a claim with modifier 78. Because the surgeon is paid only the intraoperative allowance, the global period remains from the initial surgery.

For instance, if a complication occurs 20 days into a 90-day global period, only 70 global days remain after the return to the operating room.