This is a special alert on the use of the 78 modifier. There are two new issues that have surfaced related to the use of the 78 modifier that we wanted to bring to your attention.
One Medicare carrier is paying for this 78 modifier incorrectly. It was recently brought to our attention that this carrier was paying $0 for a zero day global procedure preformed during a global and billed with modifier -78. Physicians were not allowed to appeal the payment.
As you are aware, if it is necessary to bill for a “related” procedure, such as a complication, performed during the postoperative period of the initial procedure, it should be reported by adding modifier –78. The procedure must be performed in an operating or “procedure room,” You receive a partial payment when providing this service equivalent to the “ inter-operative percentage” of that procedure, usually in the 60-70% range.
In researching the reason for this problem we found that the carriers’ manual, the document that CMS publishes giving the specifics of billing rules to the Medicare carriers, specifically stated that the “intraoperative percent” was to be paid. The problem is that the Medicare Fee Schedule Database list the “ inter-operative percentage” for all “000”global procedures as “0”.
However, the carrier’s manual also specifically states that “When a procedure with a “000” global period is billed with a modifier “-78,” representing a return trip to the operating room to deal with complications, carriers pay the full value for the procedure, since these codes have no pre-, post-, or intra-operative values.” The bottom line: be sure that you are being paid for all zero day global procedures performed in the OR or procedure room in which a 78 modifier has been attached, and, you should receive 100% of the Medicare payment. If you are not being paid appeal with reference to the “Medicare Carrier’s Manual. 100-4 Ch. 12, section 40.4 – Adjudication of Claims for Global Surgeries (C)”.
The second issue is related to place of service. Originally, the Medicare carrier’s manual stated that the service should be performed in a formal OR. Now, it agrees with the CPT definition that states the service could be performed in the OR or in a dedicated procedure room. It is not specific as to whether the dedicated procedure room could be in a physician’s office or not.
One carrier has made the decision to pay the -78 modifier when attached to a procedure performed in a procedures room in the office. Therefore, if you are performing a procedure to treat a complication or related procedure during the global period, in the office in a dedicated OR or procedural room (e.g. an endoscopy suite) bill for the service and append the –78 modifier.
If denied, an appeal with appropriate documentation might result in payment. However this will vary by carrier and by payer.
We have confirmed that some private payers do not have a place of service restriction on payment for complications treated in an OR or special procedures room. Therefore, in the private sector, we would also recommend billing using the –78 modifier for a complication or related service provided during the global period in a dedicated endoscopy suite.
