Differentiate Payer Rules to Collect for Surgical Complications
Remember that Medicare requires a return to the operating room before reimbursing these services. Not every surgery ends with a simple, uncomplicated recovery. In some cases, patients may experience complications either while they’re still in the surgical center or after they go home. No matter when or where the complication occurs, it can lead to some challenging coding situations. Read on to discover how to report surgical complications, what Medicare’s rules are, and the type of documentation to look for. Identify Whether the Issue Is a True Complication Not everything that happens during the global period of a surgery (or afterward) is a complication. A true surgical complication is a condition that results unexpectedly from a surgery or other procedure. Examples include: Even if one of the complications above occurs, it may not be considered a complication from a coding standpoint. Example: Suppose the physician performs dilation and curettage — 58120 (Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)). Some bleeding is expected after this procedure, so if the patient reports occasional vaginal spotting afterward, it may not be a complication. However, if the patient reports heavy bleeding that soaks through pads every 20 minutes and is accompanied by pain, that may be a complication. Know Medicare’s View on Complications According to the Centers for Medicare & Medicaid Services (CMS), complications are only covered when they’re related to the original procedure and they require a return to the operating room (OR) by the same provider. If you do return the patient to the OR for a complication, you should use the CPT® code that describes the procedures performed during the return to address the complication, CMS says. Do this instead of re-reporting the original surgery code, unless of course you do perform the same procedure again. 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 the CPT® code you reported to Medicare when addressing the complication. Example: A physician performs an upper endoscopy with balloon dilation of a narrow peptic esophageal stricture. The dilation was uneventful with no bleeding and the patient felt fine after the procedure with no pain. However, later in the day, the patient felt nauseated and vomited a large amount of blood. The patient was returned to the OR to address the complication. In this case, you would submit 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)) for the initial procedure. For the procedure to address the complication, you’d submit 43255-78 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method). Submit this with ICD-10-CM code K91.61 (Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure). Investigate How Other Payers View the Issue Most other payers have their own rules on how complications are reimbursed. Some commercial payers will have less restrictive policies than Medicare’s, which means you should reach out to each payer for their policies. If you apply CMS’ requirement, in which only returns to the OR are payable for complications, to every payer, you could be missing out on reimbursement. That’s because many commercial payers will pay claims when you address complications in the clinic or emergency department. For example: The physician performs a parotidectomy (42410) and the commercially insured patient is discharged from the hospital. During a follow-up appointment 45 days later, the physician identifies a seroma at the surgical site. They perform an incision and drainage of the seroma in the office. If the commercial payer allows it, you can report 10140 (Incision and drainage of hematoma, seroma or fluid collection) for this surgical complication with the diagnosis code L76.34 (Postprocedural seroma of skin and subcutaneous tissue following other procedure). Your payer may not require any modifiers on the claim since the diagnosis code L76.34 is in the “complications” section of the ICD-10-CM code set. But if the insurer has guidelines about using modifiers in these situations, take note of those before you submit the claim. Documentation Makes the Difference The physician’s documentation must link the complication that they addressed to the original surgery. Because not every diagnosis that occurs during the postoperative period is a complication, the documentation should clearly indicate the cause and effect link between the original surgery and the complication itself. For example: Suppose the patient has a 28 cm carcinoid tumor removed from their chest cavity and develops postoperative atrial fibrillation within two weeks after the procedure requiring cardioversion to get their heart rhythm back to normal. The documentation should clearly state the connection between the two. For instance, “Patient experienced postoperative atrial fibrillation following the tumor excision, likely due to a combination of surgery-induced inflammation and stress of a 28 cm tumor being removed from his chest cavity.” You’d submit the appropriate procedure code for the cardioversion, such as 92960 (Cardioversion, elective, electrical conversion of arrhythmia; external), along with I48.0 (Paroxysmal atrial fibrillation) as your diagnosis code. Keep in mind that cardioversion isn’t always performed in an OR, which would mean that it wouldn’t be covered by Medicare in most cases if it was related to the tumor excision, even if you appended modifier 78 to the procedure code. However, if two different providers were involved (for instance, a surgeon performed the tumor excision and a cardiologist performed the cardioversion), then both would likely be billable to Medicare. Always reach out to your provider if the documentation isn’t clear regarding whether something was a surgical complication or not. They can provide you with the information you need so you can make the determination on whether a particular postsurgical diagnosis should be considered a standard part of the original surgery or whether it’s a complication, and therefore separately billable. Torrey Kim, Contributing Writer, Raleigh, NC
