If Its Complicated, You Need Modifier 78

By Susan Dooley

When a postsurgical complication requires a return to the operating room for a Medicare patient,
following modifier 78 guidelines can save you money. If the followup procedure was serious enough that
it had to be performed in an operating room, endoscopy suite, or cardiac catheterization lab in a
hospital or ambulatory surgery center, you may be able to get paid at least partially for that procedure
by reporting CPT Modifier 78 (Unplanned return to the operating/procedure room by the same
physician or other qualified health care professional following initial procedure for a related procedure
during the postoperative period).

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

Check Out This Scenario

Say a patient underwent left total hip replacement (27130, Arthroplasty, acetabular and proximal
femoral prosthetic replacement [total hip arthroplasty], with or without autograft or allograft), did well
and was discharged home, but 10 days postoperatively develops severe pain and fever and returns for
further care. Your surgeon determines the patient developed a severe hip infection, readmits the
patient to the hospital, and takes her back to the operating room for incision of the left hip joint with
drainage of the infected material. When you submit the claim for this second procedure, append
modifier 78 to the code for the arthrotomy, 27030 (Arthrotomy, hip, with drainage [e.g., infection]).

Dont Forget Your Diagnosis Code!

Remember, though its possible your preop diagnosis and reason for return to the operating room could
be the same as for the first procedure, thats not necessarily the case. In the scenario above, for
example, perhaps the initial procedure was reported with a diagnosis code like M16.12 (Unilateral
primary osteoarthritis, left hip). However, when the surgeon took the patient back to the operating
room with the infected postop total hip, you would need to link an appropriate diagnosis code to the
arthrotomy procedure, such as T84.52XA (Infection and inflammatory reaction due to internal left hip
prosthesis, initial encounter). Dont forget to follow the ICD-10 guideline requiring you to use an
additional code to report the infectious process.

Your Fee Gets Cut With Modifier 78, But Somethings Better Than
Nothing
When you file a claim with modifier 78 on a second procedure, its likely that youll collect only a portion
of the procedure fee. Why? Think of surgical procedures as having three parts: preoperative, operative,
and postoperative. When you submit modifier 78 for taking a patient back to the operating room to take
care of an unexpected complication, youve already been paid for the pre- and postoperative care
payments with the fee from the original surgery. Dont just submit a bill for a third of your regular fee
for this procedure, however. Because payers vary in the amount they reimburse for modifier 78, just
report your normal fee amount and let the payer adjust the reimbursement rate.

What Do You Think?

Have any tips for modifier success? Let us know!

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The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com