General Surgery Coding Alert

A lot of potential reimbursement is left on the operating table because many surgeons believe that once they perform a surgical procedure, they cant bill for any postoperative visit or procedure, even those totally unrelated to the surgery. The neglected reimbursement reflects widespread confusion over global surgery packages established by the Health Care Financing Administration (HCFA), which administers Medicare.

Nancy King, CPC, a coder at South Louisiana Medical Associates, a multispecialty group (including three general surgeons) at the Leonard Chabert Medical Center in New Orleans, LA, comments, It is confusing because Medicare guidelines say anything connected to surgical procedures is locked. But other guidelines say you can bill if the situation is out of the norm.

Kings uncertainty is shared by many other general surgery coders and underlines the importance of understanding how the complex global package system works.

Interpreting HCFAs Global Package

HCFA set up the global system with rules and guidelines to ensure standardized reimbursement for the same services across all jurisdictions. The Medicare-approved amount for surgery covered by a global package includes payment for some, but not all, services related to the surgery when furnished by the physician who performs the surgery or by members of the same group within the same specialty. Any care or procedure listed in the package that is performed during the global period10 days for minor procedures, 90 days for major surgerycannot be claimed separately. Postoperative periods also apply to some procedures that may not be considered surgical.

According to CPT 1999 guidelines, listed surgical procedures include the operation per se, local infiltration, metacarpal/digital block or topical anesthesia when used, and normal, uncomplicated follow-up care. This concept is referred to as a package for surgical procedures, commonly referred to as global surgery or the global package.

CPT 1999 goes on to say that follow-up care for diagnostic procedures (e.g., endoscopy, arthroscopy, injection procedures for radiography) includes only that care related to recovery from the diagnostic procedure itself. Care of the condition for which the diagnostic procedure was performed or of other concomitant conditions is not included and may be listed separately.

Note: The Medicare Physician Fee Schedule Data Base (MPFSDB) provides the postoperative periods that apply to each procedure. The payment rules for global surgery apply to codes with entries of 000, 010, and 090 and YYY. Codes with 000 and 010 postoperative periods are either minor procedures or endoscopies; codes with a 090 postoperative period are major surgeries; and codes with YYY are carrier-priced codes, for which the carrier determines the global period.

Complications and New Diagnoses

Like any treatment directly related to the original procedure, routine complications following surgeryinfection, bleeding, leaking anastomosis, perforation, simple dehiscence, eviscerationare included in the global package for the surgery.

However, depending on the carrier and the particular circumstances, both examinations and surgical procedures for non-routine complications may be billable if they are reported with new primary diagnoses as are new problems with new primary diagnoses, says Arlene Morrow, CPC, CMM, an independent coding specialist in Tampa, FL.

For example, the surgeon performs a splenectomy (38100, splenectomy, total [separate procedure]; 38101, partial [separate procedure]), and the patient develops a significant wound dehiscence. Depending on how severe the dehiscence is, some commercial carriers can be billed for an E/M visit at the appropriately documented level using modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period).

Medicare, on the other hand, will not pay for an E/M service in this scenario because the dehiscence is a complication of the original procedure. HCFA guidelines state that services submitted with the -24 modifier must be sufficiently documented to establish that the visit was unrelated to the surgery. An ICD-9 code that clearly indicates that the reason for the encounter was unrelated to the surgery is acceptable documentation.

It is important to contact individual payers to find out whether they will accept the -24 modifier in the scenario described above. And if the commercial carrier does accept it, that acceptance should be obtained in writing to ensure the carrier doesnt return subsequently submitted claims as denied for reimbursement.

Both Medicare and commercial payers will pay for the procedure (12020, treatment of superficial wound dehiscence, simple closure; 12021, with packing; 13160, secondary closure of surgical wound or dehiscence, extensive or complicated). The new primary diagnosis, wound dehiscence (998.3, disruption of operation wound; dehiscence of operation wound), should be used in conjunction with any E/M or surgical procedure claim. The procedure would be billed with modifier -78 (return to the operating room for a related procedure), which Morrow calls the complications modifier.

ICD-9 codes that begin with 996-998, like the wound dehiscence diagnosis mentioned earlier, are considered post-op complication codes. If a new procedure was performed, the presence of these codes is one clue to indicate that a -78 modifier may be in order.

Note: Because modifier -78 indicates a complication of the original surgery, reimbursement will be intraoperative only, which means it is discounted and the carrier will pay a partial surgical allowance that covers only the new procedure, not pre- and postoperative costs.

Billing for Staged or Related Procedures

After operating on a patient, the surgeon may know in advance that he or she might have to perform another procedure within the original surgerys 90-day global period. For example, a patient with severe diabetes has gangrenous toes. The surgeon treats the patient conservatively, and may need to amputate some toes. Subsequently, if the patients condition hasnt improved, a below-the-knee amputation (27880) may be required. It would need a -58 modifier (staged or related procedure or service by the same physician during the postoperative period), says Anne Cunningham, RN, MBA, the compliance manager at Boston Medical Center in Boston, MA.

Modifier -58 is used when the surgery was:

planned prospectively at the time of the original procedure (staged);
more extensive than the original procedure; or
for therapy following a diagnostic surgical
procedure.

If a patient returns to surgery for a procedure that is neither staged nor the result of a complication, modifier -79 (unrelated procedure or service by the same physician during the postoperative period) should be appended to the procedure code.

Note: Modifier -58 should not be used for complications caused by the original surgery.

Successfully Bill for Subsequent and Discharge Services

Global packages also affect whether surgeons may bill for discharging patients. The Office of the Inspector General (OIG) is currently probing physician billing for discharge day management (99238, hospital discharge day management; 30 minutes or less; 99239, more than 30 minutes). A lot of surgeons are billing these codes even though HCFA regulations clearly state discharge day management services are already included in the postoperative global period.

However, even though Medicare and private carriers will not pay for discharge services considered part of a global package, some carriers may pay discharge services if the patient receives a second, unrelated diagnosis. In these situations, hospital discharge management should be billed.

For example, a patient who had an open appendectomy goes into urinary retention the next day and is seen by the surgeon. The surgeon can bill a subsequent hospital visit (99231-99233) with a -24 modifier for every day he or she visits the patient, using a new diagnosis of urinary retention (788.2), provided there is indication in the documentation that urinary retention is being treated.

The note should support the contention that this is not a complication of the original surgery; this is a new, unexpected problem. The surgeon also may be able to bill for the discharge using the hospital discharge day management codes (99238-99239) with a -24 modifier attached, depending on the carriers policy. Consult your carrier rules to find out if the discharge E/M may be claimed, and be sure to obtain the answer in writing.

For all claims involving reimbursements during a global period, Morrow also recommends coders submit an indications paragraph in the operative report to give a mini-history, because the person reviewing the claim for the carrier doesnt have the hospital chart to check it against.

Even more than usual, successful reimbursement for procedures or visits during global periods is contingent on appropriate documentation of medical necessity.