To align with CMS claim processing guidelines, Sanford Health Plan will reduce Medicare reimbursement for claims submitted with modifier 78, Unplanned return to OR, for claims processed on or after Oct. 1, 2026. This applies only to our Medicare lines of business.

Claims editing will automatically capture modifier 78, cross-reference the CPT code with the CMS National Physician Fee Schedule Relative Value File and then reduce the allowed amount to the intra-operative percentage. Providers should continue to bill full charges, and the reduction will calculate the CMS percentage automatically. Claims with modifier 78 processed prior to October 1 may pass through initial processing at full standard rates; post-payment audits will recoup overpayments.

For more information, please reference: CMS Internet-Only Manual (IOM), Publication 100.04, Medicare Claims Processing Manual, Chapter 12, Section 40.4.C

To append modifier 78, documentation and coding must meet three strict criteria:

• Strictly for complications: The return to the operating room must be to treat a complication directly resulting from the initial surgery (e.g., post-op hemorrhage, infection requiring debridement).
• The OR requirement: The procedure must take place in an official operating suite, endoscopy suite or cardiac catheterization lab. Procedures done at the patient’s bedside or in a standard exam room do not qualify for modifier 78.
• Global period match: This edit applies strictly to procedures with a 010-day or 090-day global period.

Please note: adding modifier 78 does not reset the global period; your team should expect the remaining days of the original global window to carry over uninterrupted. Any standard, routine post-operative care related to either procedure during this remaining window will still be considered part of the initial global package and cannot be billed separately.