78 Return to the Operating Room for a Related Procedure During the Postoperative Period:
The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the 78 modifier to the related procedure.
When treatment for complications requires a return trip to the operating room, physicians must bill the CPT-4 code that describes the procedure(s) performed during the return trip. If no such code exists, use the unspecified procedure code in the correct series, e.g., 47999 or 64999. In this situation, you must include operative notes with the claim or a narrative description which will allow us to understand the extent of the service performed. The procedure code for the original surgery is not used except when the identical procedure is repeated.
An operating room for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room or an intensive care unit ( unless the patient’s condition was so critical there would be insufficient time for transportation to an operating room).
A partial colectomy is performed in the hospital on January 1, 2007. The postoperative designation for this procedure (code 44140) is 90 days.
On January 15, 2007, the patient is returned to the operating room for a secondary suture of the abdominal wall. This procedure should be reported as 4990078.
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