Gastroenterology Coding Alert

Remember that when you're coding complications, modifier 78 isn't the only option you need to consider.

For Medicare carriers, you cannot charge separately for complications that the surgeon handles in an outpatient setting. These could include infection, bleeding or perforation. The surgery's global period covers such services, according to Medicare guidelines.

Watch for private-payer exception: Private payers, however, may allow you to report a separate service if the surgeon treats a complication in the office. Payers that follow CPT guidelines do not consider postoperative infections as necessarily "related" to the initial surgery. Modifier 24 (Unrelated evaluation and management service by the same physician during postoperative period) indicates to the payer that the E/M service during the global period of the initial service is for a "new" problem (for instance, a post-procedure infection) and is therefore not bundled as part of the global surgical package.

Don't Expect Total Reimbursement

When you're filing claims with modifier 78, you shouldn't expect to receive the full fee schedule reimbursement amount.

How much will an insurer pay? Payers typically won't reimburse more for the complication than the total intraoperative portion of the allowed amount -- about 80 percent in most cases.

Don't scale back billing: When using modifier 78, report your normal charge and allow the carrier to adjust the reimbursement rate.

If you cut your fee, you could find your reimbursement reduced twice.

Keep track of time: The global period for the original surgery is not reset by the return to the OR as described by modifier 78, said Lisa Rickert with Doctor's Billing Inc. in Hanover, Mass.