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General Surgery Coding Alert

Global Periods, Part 2:

To Bill or Not to Bill? Handle Complications the Right Way

Published on Tue Jul 01, 2003

Although not uncommon, complications following surgery are an uncommonly troublesome coding challenge. Because CPT and CMS definitions of typical postoperative care differ significantly, whether you should report post-op complications depends on the payer as well as the services or procedures provided.

Whats Typical? It Depends on Whom You Ask
 
Under the concept of a global surgical package, carriers bundle or include payment for services integral to a surgical procedure as a part of the procedure and not independently reportable for separate reimbursement, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a physician reimbursement consulting firm in Lakewood, N.J., and vice president of the Coding and Reimbursement Network. For example, compensation for writing orders and conducting hospital rounds during the postoperative period is included in the payment for the surgical procedure, as are other aspects of typical postoperative follow-up care. But CPT and Medicare differ in their definitions of typical postoperative care. What Medicare recognizes as a part of the global surgical package, CPT might define as a separately reportable complication.
 
CPT specifies that follow-up for therapeutic surgical procedures includes only that care which is usually a part of the surgical service. Therefore, you may separately report complications, exacerbations, recurrence or the presence of other diseases or injuries requiring additional services. Similarly, follow-up for diagnostic surgical procedures includes only that care related to recovery from the diagnostic procedure itself, CPT says. Care of the condition for which the diagnostic procedure was performed or of other concomitant conditions is not included and may be listed separately.
 
CMS regulations are stricter and more inclusive than CPT guidelines, and bundle into the global package all additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications. The only exceptions occur when the patient has problems that are unrelated to the surgery, or complications that require a return to the operating room (OR). Medicare also specifically includes the following as part of the global package:
  dressing changes
  local incisional care
  removal of operative packing
  removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts and splints
  insertion, irrigation and removal of urinary catheters, routine peripheral IV lines, nasogastric and rectal tubes
  changes and removal of tracheostomy tubes.
  
 You should further note, The services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, physicians offices. Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon, according to CMS. Under certain circumstances, however, you may report critical care services separately (see Understand Global Periods and Avoid a World of Hurt, General Surgery Coding Alert June 2003, for more information).

Modifiers Might Be Necessary 
 
Whether you report services for treatment of a complication, therefore, depends on both the payer (Medicare or non-Medicare) and the seriousness of the problem (that is, whether it requires a return to the OR).
 
For example, a patient who has recently had surgery for a hernia (49590, Repair spigelian hernia) shows signs of infection at the site of incision. The surgeon must examine the potential infection and determine if antibiotics and/or drainage are warranted and if so, which type, for how long and in what fashion to deliver them.
 
Dealing with infections of this type comprises E/M services not considered a part of typical post-op care as defined by CPT, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.
 
For payers that observe CPT conventions, therefore, you may report the service separately using the appropriate E/M service code (for example, 99232, Subsequent hospital care, per day, for the evaluation and management of a patient ...) appended with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period). Failure to append modifier -24 would cause the payer to bundle the E/M service to the surgical procedure (in this case, 49590) as a standard postoperative visit and refuse separate payment.
 
For Medicare payers, the surgeon may not report a separate E/M code for the services described, regardless of modifier -24, because CMS bundles such additional medical or surgical services during the postoperative period as a part of the global surgical fee. Only if the surgeon provides an E/M service during the global period that is totally unrelated to the surgery (although not necessarily to the underlying condition) may he or she report the service separately with modifier -24 for Medicare.
 
The situation changes if the physician must return to the OR to deal with post-op complications, Cobuzzi says. Returning to the above example, the surgeon discovers that the infection has spread to the surrounding and subcutaneous tissue, thereby requiring surgical debridement (for example, 11042, Debridement; skin, and subcutaneous tissue). In this case, the surgeon will report 11042 with modifier -78 (Return to the operating room for a related procedure during the postoperative period) appended for either Medicare or payers following CPT guidelines. The debridement falls outside the definition of typical postoperative care for CPT payers and, because the surgeon had to return to the OR, for Medicare payers as well. Most payers will reimburse only for the intraoperative portion of a procedure (that is, the surgery only no payment is made for pre- or postsurgical care) billed with modifier -78.

Dont Assume Private Payers Follow CPT
 Not all non-Medicare payers follow CPT guidelines. Many follow CMS or specify guidelines of their own, which have become increasingly restrictive in recent years. Without guidelines to the contrary, you may assume your payer follows CPT conventions. If the payer specifies its own policy, follow it to the letter. Even if the payer reimburses separately for something it considers a part of the global surgical package, you will be responsible for repayment and/or reprisals later.

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