Modifier 78: Description, Examples & Usage Guidelines

Did you know that 5.8% to 43.5% patients who undergo general surgical procedures experience post-operative complications? These complications can often lead to the patient’s unplanned return to the operating room.

That is where modifier 78 comes into play! It helps you indicate such services and ensure you are rightfully reimbursed for the related unplanned procedures.

This guide will discuss when you should append it, when to avoid it, and the key documentation requirements. So, continue reading!

What is Modifier 78?

Modifier 78 indicates the patient’s unplanned, related return to the operating or procedure room during the global post-operative period of an initial procedure. 

Important Note: It also highlights that the unplanned related procedure was performed by the same surgeon or a member of the same group specialty.

Modifier 78 – Usage Examples

Let’s review a few real-world clinical scenarios where this modifier applies:

Post-Surgical Hemorrhage

Picture a female patient who has recently undergone a total abdominal hysterectomy. However, during her time in the post-anesthesia care unit, she started showing signs of hypovolemic shock and active vaginal bleeding.

Thus, the surgeon immediately takes the patient back to the operating room to perform an exploratory laparotomy to control the hemorrhage. 

Here, you should report the exploratory laparotomy code with modifier 78. The reason? The return was unplanned and occurred during the post-operative period of the initial procedure.

Surgical Site Infection (SSI)

Assume another female patient who underwent a total hip arthroplasty. However, after ten days, she visits the clinic with a fever, purulent drainage, and redness at the incision site.

The provider orders imaging, and the findings confirm a deep subfascial abscess. Therefore, the surgeon performs an unplanned incision and drainage (I&D) in the operating room to flush the joint and debride infected tissue.

Report the I&D procedure with modifier 78 because the surgeon performed it in the operating room, not in his office.

Mechanical Failure of an Implant

Imagine a male patient who receives a posterior spinal fusion with internal fixation. However, three weeks later, the patient reports a ‘pop’ followed by intense pain.

The physician orders an X-ray, and it reveals that a pedicle screw has backed out, threatening nerve impingement. As a result, the surgeon performs the adjustment or replacement of the malfunctioning hardware in the operating room.

Here, modifier 78 applies to the specific code for hardware re-exploration since it was unplanned and was performed during the post-operative period.

Accurate Usage Guidelines for Modifier 78

The following are some of the essential billing guidelines for using this modifier:

Understand When to Use Modifier 78

Listed below is the key criterion for using this modifier:

• Append it when the procedure was not anticipated/scheduled at the time of the original surgery.
• You can use it when the procedure takes place in an operating room or a qualified procedure room.
• It is applicable only when the same healthcare provider or a member of the same specialty in the same group practice performs both procedures.
• The second procedure should be for a complication or a necessary extension directly linked to the first surgery.
• Report it when the surgeon performs the second procedure during the 10-day to 90-day post-operative window of the original procedure.

Know When NOT to Append Modifier 78

Misuse or overuse of this modifier can trigger audit risks. Thus, you should never use it when any of the following is true:

• Did the healthcare provider handle the complication in an emergency room or in a standard examination room? If this is the case, avoid appending it.
• When the physician knows during the original surgery that a second procedure is likely, such as multi-stage repair, do not append modifier 78. Append modifier 58 instead.
• You may encounter a scenario where the patient returns to the operating room during the post-operative period of the original surgery for an unrelated service. When this happens, 78 does not apply. Instead, report the second unrelated service with modifier 79 to ensure 100% payment and start a new global period.
• In case a different physician from a different group practice handles the complication, report the procedural code without any modifier.

Fulfill Documentation Requirements

Detailed documentation serves as evidence for why you have used a certain modifier. Here’s what you should include while reporting a service with modifier 78:

• Explicitly state that the surgeon performed the procedure in the operating room or in a qualified procedure room, such as an endoscopy suite, cardiac cath lab, laser suite, etc.
• Explain the complication due to which the patient returned to the operating room during the post-operative period of the original surgery. It will also help establish the medical necessity of the performed service.
• Clearly state how this procedure links to the original surgery.

Modifier 78 vs. 79: Knowing the Difference

The table below offers an at-a-glance view of the key differences between modifier 79 and 78:

	Modifier 78	Modifier 79
Relationship with the Initial Procedure	Related (usually a complication).	Unrelated (different problem).
Scope	Unplanned return to the operating room.	It can be planned or unplanned.
Global Period	It does not reset the global period.	It starts a new global period.
Diagnosis	Symptoms or diagnosis are usually the same or related to the first surgery.	It must be a different or unrelated diagnosis.
Reimbursement Rate	It reduces reimbursement.	It ensures payment at 100% of the allowed rate.

Final Thoughts on Modifier 78

With that said, it is time to bid farewell. However, before we conclude, let’s summarize the key takeaways.

We explained that modifier 78 highlights to the payer that the return to the operating room was unplanned and related. Besides, the second procedure is performed by the same physician or a member of the same group practice during the global period of the original procedure. 

That’s not all, this second service must be conducted in the operating room or a qualified procedure room. In case the physician renders it in his office, this modifier does not apply.

Phew! So many details to follow through. If you want professional help, feel free to outsource medical billing and coding services to NeuraBill.

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