May 15, 2017
Provide guidelines for the reimbursement of eligible services appropriately appended with Modifier 78 by professional providers.
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.
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.
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.
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.