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Modifier 78

Reimbursement Policy:
Modifier 78

Effective Date:
May 15, 2017

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

Scope:
All products are included, except products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap) and COB. All Insured and Administrative Services Only (ASO) accounts are included.

Definition:
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 who 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.

In instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

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.

Policy 085_V1.0_01202017