Modifier 78 for an Unplanned Return to the OR in Eye Surgery

What Is Modifier 78?

Modifier 78 is a CPT modifier for an unplanned return to the operating or procedure room by the same physician or group, during a global period, for a procedure related to the first surgery. It lets the surgeon bill the new procedure instead of having it absorbed into the first surgery's package.

All 3 conditions must be true. The return was unplanned, the problem was related to the first surgery and the procedure needed an operating room or dedicated procedure room. A second procedure that was planned from the start uses modifier 58 instead. Modifier 78 is one of the global period modifiers in ophthalmology modifiers.

When Does Modifier 78 Apply in Eye Surgery?

Modifier 78 applies when a complication or related problem after eye surgery is fixed with a procedure in the operating room or a dedicated procedure room. Cataract surgery, glaucoma surgery and retinal detachment repair produce most of these cases.

The table lists common eye care returns to the operating room with the usual code.

Each example assumes the same surgeon or group and a return to an operating or dedicated procedure room. Confirm each code against the operative note.

What Counts as an Operating Room for Modifier 78?

Medicare counts any place that is equipped and staffed only for performing procedures, which includes a hospital operating room, an ASC and a dedicated laser suite. CPT now describes the setting as an "operating/procedure room."

A procedure in a regular exam room does not qualify, even when a laser sits in that room. For Medicare, a complication treated in the exam room is part of the global package and is not paid. Some commercial payers pay for it, so check each payer's policy.

How Much Does Medicare Pay for Modifier 78?

Medicare pays only the intraoperative portion of the procedure billed with modifier 78, and no new global period starts. The surgeon is already paid for post-op care through the first surgery.

The Medicare Physician Fee Schedule splits each surgical code into pre-op, intraoperative and post-op percentages. A procedure with modifier 78 is paid at the intraoperative percentage of its fee. Procedures with a 0-day global period are paid at the full amount because they have no separate post-op share.

Why does the global period not restart?

The return to the operating room treats a problem from the first surgery, so the post-op care that follows is still care for that surgery. The first global end date stays the same, and visits for the same problem stay included until it ends.

How Is Modifier 78 Different From 58 and 79?

Modifier 78 is for an unplanned, related procedure in the operating room, modifier 58 is for a planned or more extensive related procedure and modifier 79 is for an unrelated procedure. Each one pays differently, so the choice changes the payment.

YAG capsulotomy during the cataract global period is the case coders debate most. It is most often billed with modifier 79 because posterior capsule opacification is a new condition, but some payers read it as related.

Which Diagnosis Goes on a Modifier 78 Claim?

A modifier 78 claim lists the complication or related condition that caused the return to the operating room, not only the original diagnosis. The complication code explains why a second procedure was needed so soon.

These ICD-10-CM codes are common on cataract-related returns.

• H59.02- for cataract lens fragments left in the eye after cataract surgery
• T85.22XA for displacement of an intraocular lens, initial encounter
• H59.03- for cystoid macular edema after cataract surgery, when surgery is needed

Each code with laterality must match the eye modifier on the procedure line. More diagnosis rules are in the ophthalmology ICD-10 codes list.

What Does a Modifier 78 Claim Look Like?

A modifier 78 claim bills the return procedure with modifier 78 and the eye modifier, linked to the complication diagnosis. The example shows a lens implant repositioned 3 weeks after right eye cataract surgery by the same surgeon.

Payment modifiers go before the eye modifier, so the line reads 66825-78-RT.

Why Do Modifier 78 Claims Deny?

Modifier 78 claims deny most often because the procedure was done in an exam room, a different surgeon used the modifier or the diagnosis does not show a related problem. These steps prevent most of them.

1. Confirm the room. The procedure was in an operating room, ASC or dedicated procedure room.
2. Confirm the surgeon. The same physician or group performed the first surgery.
3. Code the complication. List the related problem that caused the return.
4. Add the eye. Bill RT or LT after modifier 78.

Our cataract surgery billing team tracks every global period, and our ophthalmology medical coding services check each return to the operating room before the claim is sent.