Gastroenterology Coding Alert

There's some wiggle room in the definition of 'operating room'

When reporting your gastroenterologist's surgical procedures, make sure you're clear about whether the setting qualifies as an operating room before you append modifier -78 to the procedure code.

The good news: There are places of service other than a traditional operating room that payers may consider proper for performing OR-type procedures.

The bad news:  The interpretation of OR can vary by region and/or payer, and it's often difficult to tell what a payer will consider an OR, says John Burns, CPC, president of  Modern Conventions in Compliance Inc. in Gansevoort, N.Y.
 
Call Carrier Before Making Ultimate Choice

Once you've checked the operative notes and confirmed the place of service, make sure you call your carrier to make sure it also considers the setting an operating room. If the payer says the setting is an OR, you can use modifier -78 (Return to the operating room for a related procedure during the postoperative period) on your claim.

Many coders misinterpret the term "operating room," assuming it's a setting that's only used for operations and no other types of service. This isn't necessarily the case, Burns says.

Definition: An "operating room" is a room equipped for performing surgical operations. "Payers may deem certain places of service inappropriate, but we feel that places of service like an ambulatory surgical center (ASC) or endoscopic surgical suite would meet definition requirements for 'operating room,' " Burns says.

1 Payer's OR Policy

Here is the OR definition for HGSAdministrators (HGSA), the Medicare carrier for Pennsylvania:

"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," according to the HGSA Web site.

"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)," HGSA says.