Description

It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure.

Per CMS and CPT, modifier 78 should be reported with procedure codes for treatment of postoperative complications that require a return trip to the operating room.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reduce payment per CMS guidance for unplanned return to surgery services, as indicated by modifier 78. 

Reimbursement Guidelines

Claims filed with modifier 78 are eligible for an allowed reimbursement according to the intra-operative % value on the current CMS Physician Fee Schedule.

A 78-modifier payment reduction will apply to any service with a 10- or 90-day global period containing an intraoperative percentage, per the Medicare physician fee schedule.

Modifier 78 may only be submitted with surgical codes.

Modifier 78 may not be submitted with modifier 80-82. Submit these claims with the appropriate assistant-atsurgery CPT modifier (80-82) only.

A new global period will not be initiated with the return trip to surgery, as indicated with modifier 78.

Rationale

In alignment with CMS and correct coding initiatives, Blue Cross NC will reduce reimbursement for services filed with modifier 78.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.

Related policy

Split Surgical Package

Modifier Guidelines

References

American Medical Association, Current Procedural Terminology (CPT^®)

CMS Medicare Claims Processing CMS Pub 100-04: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3721CP.pdf

History

12/31/2022 - New policy developed. Blue Cross NC will reduce reimbursement for services filed with modifier 78. (cjw)

11/1/2025 - Updated Application section to include Healthy Blue + Medicare (HMO-POS D-SNP). Notification on 11/1/2025 for effective date 1/1/2026. (dc)

Application

These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, Healthy Blue + Medicare (HMO-POS D-SNP), and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.

This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.