Medicare Compliance & Reimbursement

Don’t automatically skip billing for post-surgical infection care.

If you’re pondering whether services for a post-op complication are included or are reported separately, you’ll benefit from two tips about when you should bill for post-op care.

Tip 1: Distinguish Between Medicare and Non-Medicare Patients

Medicare treats postoperative complications, including infections, differently than insurers who follow CPT® guidelines. Although both CMS (Medicare) and CPT® guidelines indicate that the global surgical package includes "typical" postsurgical care, the two sources differ regarding what qualifies as typical -- which means you must differentiate your claims depending on which payer you are coding for.

Medicare requires that a complication be significant enough to warrant a return to the operating room before you may report a separate procedure in the global period. In fact, CMS "Correct Coding" guidelines specifically state, "When the services described by CPT® codes as complications of a primary procedure require a return to the operating room," you may report a separate procedure.

AMA’s rule: AMA CPT® is very clear on complications in the post-operative period. CPT® states in the front of the Surgical section the following (page 54 of 2012 CPT® Professional from the AMA): "Complications, exacerbations, recurrences, or the presence of other diseases or injuries requiring additional services should be separately reported." This is found in the second column under the heading of "Follow-Up Care for Therapeutic Surgical Procedures." You’ll find similar instructions for "Follow-Up Care for Diagnostic Procedures."

Some non-Medicare payers may follow AMA CPT® guidelines and allow you to report services for treating postoperative complications that CMS typically bundles into the global period, including infection treatment that the surgeon provides in the office, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia. This means, for instance, that you may be able to collect payment from private payers for a level-three or -four established patient visit (99213 or 99214) to deal with a patient’s postoperative infection depending on the documentation.

The bottom line: If treatment of a postoperative infection requires the provider to return the patient to the operating room, you should report the procedure to either Medicare or private payers. If the surgeon can treat the infection in his office, however, you may be able to file a claim only to those payers that do not follow CMS guidelines, Pohlig says. "You should query the payers in writing beforehand to ensure proper coding and billing compliance," she says.

Private payers do not have clear-cut rules, Pohlig notes. In fact, many of their coding guidelines are contractual. "What may be negotiated for one physician group may not be included in another group’s contract," she says.

Tip 2: Decide What Modifier to Use

For both Medicare and private payers that recognize them, you’ll have to add a modifier to the appropriate CPT® code to describe the physician’s postsurgical infection treatment. If the surgeon is returning to the operating room during the global surgical period of a previous procedure, the correct modifier is 78 (Return to the operating room for a related procedure during the postoperative period). Modifier 78 "indicat[es] that the service necessary to treat the complication required a return to the operating room during the postoperative period," according to CMS guidelines. You should use modifier 78 to indicate a return to the operating room for both private and Medicare payers.

Private payer difference: For private payers that reimburse separately for in-office or bedside postoperative infection treatment during the global period, you must append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M service code, says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash. Code the diagnosis for the infection for this visit, not the surgery.

You may also have to perform a procedure, such as incision and drainage of a skin wound infection (10060 or 10061), in the office or bedside without a return to the OR for a non-Medicare payer. If so, you must put modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) on the procedure for an unrelated procedure. Although it appears that the procedure is related to the global, this procedure is being done specifically for the infection, not for the original diagnosis that led to the original surgery.

3 Examples Show You What to Do

Take a look at the following scenarios to help guide your postsurgical infection billing:

Coding example 1: Several days following a tonsillectomy (for example, 42826, Tonsillectomy, primary or secondary; age 12 or over) the patient develops an abscess (475) at the site of the incision. The patient visits the surgeon at her office. The physician prescribes antibiotics and a follow-up.

For a private payer that follows the AMA CPT® guidelines for post-operative complications, you would report an E/M service (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) appended with modifier 24, if the payer requires you to do so. The modifier is usually needed because any service in the global is automatically denied within payer software systems. Use the abscess as the diagnosis, not the reason the tonsillectomy. The abscess diagnosis shows the "unrelated" reason for the E/M service. The modifier indicates that the payer does not include the service in the initial surgery’s global fee. Had the patient been covered by Medicare, however, the office visit counts as a part of the global package, and you cannot file an additional claim.

Coding example 2: A week following surgery, the surgeon readmits the patient to the hospital for IV antibiotics but does not return the patient to the operating room. Once again in this case, you may not report a separate service to Medicare, even though the surgeon readmitted the patient. CMS guidelines specify that when the physician readmits the patient within the original surgery’s global period for complications of the original surgery, you cannot bill or charge for the readmission.

But for payers not following CMS guidelines, and following the AMA CPT® guidelines, you may be able to report an appropriate admission code (for example, 99221, Initial hospital care, per day, for the evaluation and management of a patient ...) with modifier 24 appended, Pohlig says.

Coding example 3: The patient from Example A, who develops an abscess, requires an incision and drainage in the OR (for example, 42700, Incision and drainage abscess; peritonsillar). In this case, you should report 42700-78 for both Medicare and private payers. Don’t forget the diagnosis to consider is 998.59 (Other postoperative infection), to any CPT® codes you report.

Don’t Expect Total Reimbursement With 78

When you file claims with modifier 78, don’t expect to collect the full fee schedule reimbursement amount. Procedures billed with modifier 78 include only the "intraoperative" portion of the service (no payment is made for pre- and postoperative care), and insurers generally reimburse them at 65-80 percent of the full fee schedule value, depending on the payer. But when you append modifier 78, you do not incur a new global period.