General Surgery Coding Alert

Medicare will only allow payment for return to the OR

If your surgeon sees patients for postoperative complications and bundles every service into the global period of the surgery, you could be giving up thousands of dollars yearly.

In many cases, you can legitimately report patient evaluations in the post-op period, but you must be mindful of your individual payer's rules.

If It's Unrelated, Report It

CPT rules allow you to report an E/M service with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) if the surgeon evaluates the patient for a complication during the global period of a previous procedure.

-Because payers following CPT guidelines do not consider postoperative infections as necessarily -related- to the initial surgery, for instance, you can charge for an E/M service to evaluate the patient for a postoperative infection. However, you should use the 24 modifier to tell the payer that the E/M service is distinct and not a part of the global surgical package,- says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.

Medicare Plays by Different Rules

Medicare payers (and some private payers) do not follow CPT guidelines with respect to modifier 24 and will only pay for treatment of complications during a global period if the complication results in a return to the operating room (OR), says Susan Allen, CPC, compliance coder with JSA Healthcare in St. Petersburg, Fla.

Example: Several days following hernia repair (for example, 49560, Repair initial incisional or ventral hernia; reducible) the patient develops an infection at the incision site. The patient visits the surgeon at her office. The surgeon inspects and opens the wound to drain the infection, changes the patient's dressings and administers antibiotics.

For a private payer following CPT guidelines, you may report an E/M service (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 24 appended. The modifier indicates that the service is not included in the initial surgery's global fee.

For a Medicare payer, however, you must count the office visit as a part of the surgical package, and you cannot file a claim for additional reimbursement.

Bottom line: Know whether your payer follows CPT or CMS guidelines before you report a postoperative complication service with modifier 24.
 
78 Is the Answer for Complications Treated in OR

If the surgeon must treat the patient in the OR for complications during the global period, you may report the treatment separately by appending modifier 78 (Return to the operating room for a related procedure during the postoperative period) to the appropriate CPT code, Allen says. This is true for Medicare and private payers.

Example: The patient in the above example has more severe infection, reaching deeper into the surgical wound. To treat the infection, the surgeon returns the patient to the OR for debridement (11000, Debridement of extensive eczematous or infected skin; up to 10% of body surface). In this case, you should report 11000-78 for both CPT and CMS payers.