Modifier 78.

When billing a carrier for the cost of returning a patient to the operating room for management of a complication, you should use modifier 78 on the claim form. This modifier should be used only when the follow-up procedure is performed as a separate procedure at a different time; you cannot use this modifier when the complication was treated during the initial procedure.

Let's look at an example of a reimbursement claim for a patient who underwent a tonsillectomy on Oct. 1 (figure). Note that the commercial payment for the procedure was $345.50. On Oct. 8, the patient was taken back to the operating room for control of post-tonsillectomy hemorrhage. The reimbursement for that procedure was $530.93. Note that the provider was paid more for taking care of the complication than for performing the initial procedure. (There was a difference in relative value units: 42826 = 6.68 and 42961 = 11.)

While it is difficult to understand how a surgeon can be paid more for treating a complication than for the initial procedure, the appropriate use of the 78 modifier in this case at least permitted some reimbursement for managing the complication.

Dr. Isenberg is an otolaryngologist in private practice in Indianapolis; [e-mail]

Figure. Sample explanation of benefits shows entries
for the tonsillectomy (42826) on Oct. 1, follow-up control
of post-tonsillectomy hemorrhage (42961) on Oct. 8, and the
78 modifier denoting the return to the operating room during
the global period. Note the difference in reimbursement for
the initial tonsillectomy and the follow-up procedure.

Member                     Diag      Procedure
Name          DOS          Code      Code

Doe, John B   10/01/05     474.00    42826
Doe, John B   10/08/05     784.80    42961 (+78)

              Billed       Allowed   Non-Cov
              Amt          Amt       Amt

Doe, John B   1,200.00 *   345.50
Doe, John B     605.00 *   530.93

                                     Amt Pd
              Deduc        Coins     Provider

Doe, John B   0.00         0.00      345.50
Doe, John B   0.00         0.00      530.93

* Fees represented are examples only. Percentage
of reimbursement is based upon actual data.