Define OR for Successful Modifier 78 Use
Question: I work for a surgery practice, and I’ve been using modifier 78 when patients return to our office and enter an exam room with their surgeon for an unplanned service. Since we do procedures in those rooms, I’ve assumed they count as procedure rooms. I recently learned that modifier 78 should really only be used at hospitals. Is this true? AAPC Forum Participant Answer: Although the descriptor for modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) mentions procedure room, it actually refers to the room in which the initial surgery was performed. In the Medicare Learning Network (MLN) Global Surgery Booklet, the Centers for Medicare & Medicaid Services (CMS) defines an operating room (OR) as: “a place of service specifically equipped and staffed solely for doing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It doesn’t include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition is critical so there’s not enough time for transporting to an OR).” The situation you describe is not an operating room according to this definition, and so modifier 78 would not be appropriate in the circumstances you describe. Modifier 58 (Staged or related procedure or service by the same provider during the post-operative period) may be appropriate for this situation. CMS says the modifier “helps bill staged or related surgical procedures during the first post-operative period procedure.” Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC
