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Clinical Editing for Modifier 78

August 28, 2020

To: All Providers

Contracts affected: Commercial and Medicare Advantage

Starting December 1, use of Modifier 78 will be processed through our clinical editor, instead of being adjusted on a post-payment basis. This will allow claims to process correctly. And all procedures using Modifier 78 will be reimbursed at a flat rate of 70% of the fee schedule for the original procedure. Modifier 78 currently is reimbursed at 60-80% of the fee schedule depending on the procedure. Modifier 78 is used for:

  • An unplanned return to the operating (OR) or procedure room by the same physician
  • For a procedure related to the original procedure during the post-operative period
  • Professional services only (no facility or ancillary charges)

Modifier 78 is appropriate when the procedure is an outgrowth of the original surgery, not the original condition. There are two caveats for using Modifier 78:

  • The patient must be returned to the OR or procedure room (such as an endoscopy suite) and the procedure may not be performed anywhere but there
  • The reason for the subsequent surgery is related to the original surgery, meaning that the procedure is intended to address a complication of the original surgery

Please note: Modifier 58 is similar, but is used only for a planned or anticipated procedure related to the original condition, and might include therapy following a surgical procedure.

Please contact your account representative with any questions about this change.

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