General Surgery Coding Alert

See the case examples on page 3.

Now that you’ve read the four scenarios on page 3 and tried your hand at coding them, read on to see what our experts identify as correct coding. Pay special attention to how the proper modifier can help ensure proper pay for procedures and evaluation and management (E/M) services performed during a surgical global period.

Answer 1: Know When to Use Modifier 58

You should code the initial procedure using 11643 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm). Remember that the excision has a 10-day global period.

The correct code for the tissue transfer is 14060 (Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less). But recall that adjacent tissue transfer or rearrangement codes include the lesion excision, according to CPT^® guidelines.

Global: Because the tissue transfer happens during the 10-day global period for the excision procedure, reporting both 11643 and 14060 is problematic.

Solution: You should list the second procedure with modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period). According to CPT^® coding guidelines, you may use modifier 58 for “the performance of a procedure or service during the postoperative period [that] was: (a) planned or anticipated (staged); (b) more extensive than the original procedure …”

Tip: Notice that modifier 58 does not require a return to the operating room (OR).

Cost impact: When you use modifier 58, the global period restarts, so your surgeon should get 100 percent payment for the service.

Answer 2: Reach For Modifier 78

Report the initial procedure using 44120 (Enterectomy, resection of small intestine; single resection and anastomosis). The correct code for the procedure five days later is 49002 (Reopening of recent laparotomy).

Do this: You should append modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period) to 49002.

Here’s why: Several factors of this case make modifier 78 the correct choice:

• The second procedure occurs during the 90-day global period of the first procedure.
• The same physician performs the second procedure.
• The 49002 procedure involves a return to the OR
• The reopening of the laparotomy is related to the initial procedure.

Key: “When deciding between 58 and 78, a major clue is whether the second procedure was planned [use 58], or due to a complication [use 78],” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia.

Cost impact: Unlike modifier 58, using modifier 78 does not start a new global period. The surgeon should expect to receive reduced pay for the second procedure, accounting only for the intraoperative part of the service.

Answer 3: Know When To Use Modifier 24

The correct code for the appendectomy is 44950 (Appendectomy). Because there is no indication of infection or rupture, you should not choose 44960 (Appendectomy; for ruptured appendix with abscess or generalized peritonitis).

E/M: The surgeon documents an office visit involving 24 minutes with an appropriate history and exam, so you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter).

While the evaluation and management (E/M) service occurs during the 90-day global period for the surgery, it does not constitute postoperative follow up examination or care of a recent surgical wound. Instead, the visit is to evaluate a separate, unrelated condition.

Do this: You should report 99213 with modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period).

Modifier 24 tells the payer, ‘Yes, the service was rendered during this patient’s global period, but it’s not related. It has nothing to do with that surgery,’” according to NGS Medicare’s Nathan Kennedy during the Part B payer’s recent webinar, “Medicare Global Surgery Policy.”

Keep in mind that in order to report modifier 24, the E/M service must meet these criteria:

• The E/M service must occur during the postoperative period of another procedure.
• The current E/M service must be unrelated to the previous procedure.
• The same physician (or tax ID or same group and specialty) who performed the previous procedure must provide the E/M.

Details: Medicare and many other payers have very specific guidelines for what qualifies as “related” to the original procedure and what doesn’t. For instance, Medicare will always treat postoperative infections as related to (and therefore, included in the global surgical package of) the initial surgery (except if the infection involves a return to the OR, as you saw in scenario 2).

Cost impact: Because you appropriately used modifier 24, your practice should expect to receive a separate payment for the E/M service that the surgeon performed during the surgical global period.

Answer 4: Capture Extra E/M With Modifier 25

You should code the excision procedure using 11401 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm).

The 11401 procedure on that date includes the E/M service to evaluate the cyst and form the decision for surgery. That’s why National Correct Coding Initiative (NCCI) edits bundles an E/M code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter) as a column 2 code with 11401.

Exception: In this case, the surgeon also performed an E/M service to assess the breast lump and create a treatment plan. That work was separate from the minor cyst-excision exam and procedure.

The example doesn’t provide enough information to determine the E/M level for the breast lump evaluation, but assuming that it’s 99212, you should report that code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Problem: Modifier 25 is ranked as one of the most commonly rejected modifiers, according to Juan Lumpkin, provider relations senior analyst at CGS Administrators, LLC in Nashville, Tennessee during the Part B payer’s webinar “Avoiding Modifier Rejections.” That’s why the documentation must fully describe the E/M service that is not associated with the procedure if you want to avoid a denial.

Cost impact: Appropriately appending modifier 25 means that your practice should receive a separate payment for an E/M service that the surgeon performs on the same day as a procedure or other service.