Wiki Modifier 78 and billing for an E/M code

[devine1]

I have read that the 78 modifier does not restart the global period. However, I am receiving denials for these visits stating that they are within the global period, but the original procedure is out of the global period.

Example, patient had a procedure on 12-11-16 and it is a 90 day global.

Patient returned to the OR on 3-9-17 and we used the modifier 78 since it was a complication from the initial surgery.

Patient then came in for follow up visit on 3-27-17 and the insurance is denying the visit as within the post op global.

Any ideas on how to get paid for these follow up E/M's or are they global?

 

[thomas7331]

This would depend on payer policy. Some payers, for surgeries submitted with modifier 78, will reimburse the surgery at a reduced rate because they are only paying the intraoperative portion of the surgery under the assumption that the pre- and post-operative care for the related surgery were already paid as part of the original surgery's global package. If this is the case, there should be no new global period for the surgery with modifier 78. However, if the payer allowed the full rate for the surgery billed with modifier 78, then this would start a new global period because they are reimbursing you for the whole global package which would include any follow-up care during the global period of that surgery as well. So you should be able to tell whether or not the modifier 78 would restart a global period by looking at your payment for that procedure and if you received the full global payment per your fee schedule, then a new global period does apply.

 

[devine1]

Thank you for the information. It is very helpful.