Effective Date: January 1, 2019

Purpose:
Provide guidelines for the reimbursement of eligible services appropriately appended with Modifier 78 by professional providers.

Scope:
LOB included:

• NJ FamilyCare/Medicaid
• Medicare Advantage Dual Special Needs (HMO SNP)

Definitions:
Modifier 78 is used when there is an unplanned return to the operating room for a procedure during the postoperative period of a related surgical procedure.

Policy:
An unplanned surgical service performed in an operating room setting within the postoperative period (10-90 days) of a related, planned surgical procedure provided to that member by the same practitioner when appropriately appended with Modifier 78 will be considered for reimbursement at 70% of the applicable Horizon BCBSNJ fee schedule amount.

Procedure:
Surgical services appropriately appended with Modifier 78 shall be considered for reimbursement at 70% of the applicable Horizon BCBSNJ fee schedule when all of the following conditions are met:

• The return to the operating room is unplanned.
• The service is performed by same physician or group that performed the initial procedure.
• The service is related to the initial procedure.
• The service is performed during the postoperative period of the initial procedure (10-90 days)

In instances where the provider is participating, there shall be no member liability.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

Resources:
1. CMS Manual System, Medicare Claims Processing Manual (Pub. 100-04), Chapter 12, § 40.2, A, 5, “Return Trips to the Operating Room during the Postoperative Period”