Wiki 78 Modifier

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nharrison2

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I have a a huge increase in procedures denying included in global for California even though they have a 78 modifier on the claim and even after appeals. Has anyone else had this? Has something changed for the 78 modifier that I cannot find? I searched and searched. Is there anything I can do?
 
This is assuming that there's an unplanned return to the OR for a related procedure by the same surgeon. And it's a major surgery, not a minor procedure.
The only thing I can suggest is that CA payers may have changed some of their billing rules. I don't know of any Medicare updates, and there's been no AMA comments since 2013.

What is the denial reason that they're giving you?
 
They are denying included in global even when there is a 78 modifier. I have a few office visits that denied for inside a global. The global ended 01/019/2025 the office visits are 02/05/2025 and after patient had a unplanned return to OR on 01/09/2025 and the codes on this date are 90 day global but there is a 78 modifier on the 001/09/2025 and my appeals keep getting denied. Its really frustrating at this point.
 
nharrison2 said:
They are denying included in global even when there is a 78 modifier. I have a few office visits that denied for inside a global. The global ended 01/019/2025 the office visits are 02/05/2025 and after patient had a unplanned return to OR on 01/09/2025 and the codes on this date are 90 day global but there is a 78 modifier on the 001/09/2025 and my appeals keep getting denied. Its really frustrating at this point.
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I'm not quite understanding what is being denied, and what the timeline was. Modifier -78 is not for office visits being denied in global. It is for an additional procedure performed during the global period of a prior surgery/procedure. If appropriate, you could consider -24 on the E/Ms in a global period.
 
Ok the patient had the surgery in October of 2024 I don't remember the exact date but the global of that surgery ends 01/19/2025. From the October surgery the patient had several unplanned return to OR or procedure room procedures. The most recent unplanned was 01/09/2025 which still falls in the global for the October global. The surgery on 01/09/2025 was a 90 day global but was billed with a 78 modifier, therefore the global did not reset and the global still ended on 01/19/2025. Insurance is denying 3 99214 from 02/05/2025 to March stating these dates are included in the 01/09/2025 global but they shouldn't be because the 78 modifier does not reset the global and the patient does not need a 24 modifier because this is related. This is happening with A LOT of payers from Aetna, Meritian and Blue Shield of CA and it just started happening within the last 3 to 4 months- all of these were paid pervious with no issues. I kept researching policies and the rules behind the global and the 78 modifier and everything I am finding supports my appeals and they are still denying. Not sure what to do at this point. Can I repot the insurances?
 
OK - got it! Depending on the type of plan and your state, reporting the insurance may be an option. Before doing so, I would research the payor policy regarding modifier -78. Payors can and do set their own policies which could be different than Medicare and/or other coding guidelines. Even when it's coded correctly per coding guidelines does not necessarily mean you will definitely receive proper payment. If you have a provider rep for your area (many insurances have basically done away with them), reaching out with several examples might be an option as well. Good luck!
 
Thanks. I checked their policies and couldnt find anything that would allow them to deny. And they pay other claims on the same patient for the same codes and same modifiers. So where would I report them?
 
This can vary depending on your contract with the payor, the type of plan, and your state. Usually you need to exhaust all internal appeal processes with the carrier first. Your state's department of insurance may have more information for you.
 
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