April 13, 2023

Question:
What Modifier do I use when I have to take the patient back to the operating room to repair a post-operative hemorrhage?. My coder told me that complications are included in the payment for the original surgery. But one of my colleagues told me I can bill for the repair during the post-op period.

Answer:
Yes, you may bill for complication that sent the patient back to the OR for the repair. CPT and Medicare agree that taking the patient back to the OR to treat a complication is billable. Modifier 78 (unplanned return to the OR) is appended to the procedure code(s) performed to treat the hemorrhage.

*This response is based on the best information available as of 04/13/23.