decisionhealth Newsletters, Part B News - 2020 Issue 6 (June)
Review CMS’ definition of an OR before appending modifier 78
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Article Overview
This article discusses Medicare billing guidance for postoperative return procedures and the CMS definition of an operating room in relation to modifier 78. It is intended for surgical billing staff, coders, and practice administrators who need to understand how facility location and payer policy affect whether a return procedure is separately billable. The article also notes that private payer policies may differ and references the Medicare Claims Processing Manual as a source of guidance.
Why This Topic Matters
Understanding CMS’s definition of an operating room can affect whether a postoperative return procedure is reported separately under Medicare rules and whether a facility location qualifies for modifier 78-related billing considerations.
Article Sections
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Question
A billing scenario is presented involving postoperative return procedures performed in an office setting and questions about modifier 78 usage.
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Answer
The response summarizes Medicare guidance on postoperative return procedures, CMS’s operating room definition, and the role of payer-specific policy differences.
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Resource
A CMS manual reference is provided for further review of the guidance discussed in the article.
What You Will Learn
- How the article frames Medicare guidance for postoperative return procedures
- How CMS defines an operating room for purposes discussed in the article
- Why payer policies may affect billing considerations for similar services
- Where to find the referenced CMS manual resource
Who Should Read This
- Medical coders
- Surgical billing staff
- Practice administrators
- General surgery office staff
Modifiers Discussed
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