Cracking the Code

Modifier 78

Modifier 78 is defined as an “Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Healthcare Professional Following Initial Procedure for a Related Procedure During the Postoperative Period”. The use of this modifier can be utilized when all the following circumstances are supported. The physician or other healthcare professional must undertake the subsequent surgery because of conditions (complications) arising from an initial surgery, the subsequent surgery occurs during the global period of the initial surgery, and the subsequent surgery requires a return to the operating room.9

Q: A 13-week-old female baby had a cerebrospinal fluid shunt placed three days ago. The shunt is not draining the excess CSF and the baby returns to the OR for a shunt removal and replacement by the same surgeon who placed the original shunt. What CPT code and modifier is reported for this procedure?
A: 62258-78 Rationale: The complete removal of the cerebrospinal fluid shunt system with a replacement was performed. Let’s look at our CPT Index for Shunt/Brain/Removal, directing us to 62256-62258. In following the above directive, we would append modifier 78 as this is the appropriate modifier to append for two reasons. First, the patient is returning to the operating room following the initial procedure during the postoperative period. Second, the same surgeon performed the initial procedure and the removal and replacement of the shunt.
Reference: 2023 CPT codebook
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