General Surgery Coding Alert

Question: Our surgeon preformed a cholecystectomy (47600) on a Medicare patient. A week later the patient returned to the office with an infected incision that required debridement. The debridement was performed in the office. Should we charge for this service using modifiers -58 or -78?

Maine Subscriber Answer: No, you should not charge for postsurgical debridement in the office for Medicare patients. The infection is a consequence of the surgery and therefore cannot be classified as an unrelated, separately billable procedure. Medicare guidelines specify that normal postoperative care and complications are included as part of the global period for the procedure, which, in the case of 47600 (Cholecystectomy) is 90 days.

According to CPT, modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) is applicable when a procedure or service during the postoperative period is:

a) planned prospectively at the time of the original procedure (staged)
b) more extensive than the original procedure, or
c) for therapy following a diagnostic surgical procedure. In each case, the subsequent procedure or service is either related to the underlying problem/diagnosis that prompted the initial surgery or anticipated at the time the initial surgery is performed (or both). The patient's condition, rather than the results of a previous surgery, dictates the need for additional procedures: Modifier -58 should not be used if subsequent procedures are necessary due to surgical complications or unexpected postoperative findings that arise from the initial surgery. Modifier -78 (Return to the operating room for a related procedure during the postoperative period) also refers to "related procedure" in its descriptor. Unlike modifier -58, however, modifier -78 applies when the related procedure is undertaken as a result of conditions arising from the initial surgery, rather than from the patient's condition. Modifier -78 should be used only for complications arising from the original procedure although the term "complications" is conspicuously absent from CPT. Note: When in doubt (i.e., the medical record does not clearly indicate the reason for the subsequent surgery), coders should check with the operating physician prior to selecting a modifier.

Modifier -78 requires that the patient return to the operating room (OR) and cannot be applied to procedures performed in a physician office or other outpatient setting. As stated above, for Medicare payers any complications of the initial surgery that may be handled without a return to the OR (e.g., routine infection, bleeding or perforation) are covered under the global period of that surgery.

Note that non-Medicare payers, i.e., payers that follow CPT, often stipulate different guidelines and therefore may reimburse for postsurgical wound debridement and other complications treated in the physician's office. Most commonly, a superficial infection at the incision may be resolved with a [...]