General Surgery Coding Alert

If you're treating Medicare and private-payer claims the same, you could forfeit $80 or more per claim

If you're including postsurgical infection care in the global surgical package of the primary procedure every time, you're missing out on legitimate revenue. To determine if you deserve additional reimbursement, ask yourself two questions: Question 1: Who's the Payer? Medicare treats postoperative complications, including infections, differently than insurers who follow CPT guidelines. Although both CMS (Medicare) and CPT guidelines indicate that the global surgical package includes "typical" postsurgical care, the two sources differ on what qualifies as typical -- which means you must differentiate your claims depending on the payer you are billing.

"Basically, Medicare requires that a complication must be significant enough to warrant a return to the operating room before you may report a separate procedure," says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. CMS "Correct Coding" guidelines specifically state, "When the services described by CPT codes as complications of a primary procedure require a return to the operating room" you may report a separate procedure.

"But CPT guidelines are less strict," Sandham says, "and you may report some postoperative services during the global period, including treatment of infection, that the surgeon provides in the office." This means, for instance, that you could collect an additional $80 from private payers for a level-four established patient visit (99214) to deal with a patient's postoperative infection.

Here's the bottom line: If treatment of a postoperative infection requires that the surgeon return the patient to the operating room, you may report the procedure for either Medicare or private payers. If the surgeon can treat the infection in his office, however, you may only file a claim for those payers that follow CPT guidelines. Question 2: Which Modifier Do I Need? For both Medicare and private payers, you'll have to append a modifier to the appropriate CPT code to describe the surgeon's treatment of the postsurgical infection. "If the surgeon is returning to the operating room during the global surgical period of a previous procedure, the correct modifier is -78 (Return to the operating room for a related procedure during the postoperative period)," says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues, in Fountain Valley, Calif. And, modifier -78 "indicat[es] that the service necessary to treat the complication required a return to the operating room during the postoperative period," according to CMS guidelines. The use of modifier -78 to indicate a return to [...]