Neurosurgery Coding Alert

Earn an extra $80 or more per claim by knowing when NOT to follow CMS guidelines

 If you're including postsurgical infection care in the global surgical package of the primary procedure, you might be missing out on an important source of revenue. To determine if you deserve additional reimbursement, ask yourself these two questions:

Question 1: Who's the Payer?

Although both CMS (Medicare) and CPT guidelines indicate that the global surgical package includes "typical" postsurgical care, Medicare and private payers differ on what qualifies as typical -- which means you must differentiate your claims depending on the payer you are billing.

"Basically, Medicare requires that a complication must be significant enough to warrant a return to the operating room before you may report a separate procedure," says Susan Allen, CPC, CCS-P, coding manager and compliance officer for Florida Spine Institute in Clearwater, Fla. 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, according to Chapter 1 of the National Correct Coding Initiative (NCCI), version 10.1.

But CPT guidelines are less strict, and you may report some postoperative services during the global period, including treatment of infection, that the surgeon provides in the office. This means, for instance, that you could collect an additional $80 from private payers that follow CMS guidelines for a level-four established-patient visit (99214) to deal with a patient's postoperative infection.

Here's the bottom line: If treatment of a postoperative infection requires a return to the operating room, you may report the procedure for either Medicare or private payers. But if the surgeon can treat the infection in his office, you may only file a separate claim for payers that follow CPT (not CMS) guidelines.

Question 2: Which Modifier Do I Need?

For both Medicare and private payers, you'll have to append a modifier to the appropriate CPT code to describe the surgeon's treatment of the postsurgical infection.

"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)," says Julia A. Appell, CPC, a coder with General & Vascular Surgery PC in South Bend, Ind. And, modifier -78 "indicat[es] that the service to treat the complication required a return to the operating room during the post-operative period," according to CMS guidelines. The use of modifier -78 to indicate a return to the operating room applies to both private and Medicare payers.

For private payers to reimburse for in-office post-operative infection treatment during the global period, you should 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, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb. "Because payers following CPT guidelines do not consider postoperative infections as necessarily 'related' to the initial surgery, you can charge for an E/M service. However, you should use the -24 modifier to indicate that the E/M is not a part of the global surgical package."

Don't forget the diagnosis: In all cases, you should link an appropriate diagnosis, such as 998.59 (Other postoperative infection), to any CPT codes you report.

Examples A, B and C Show You What to Do

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

Coding Example A: Several weeks following diskectomy (for example, 63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) the patient develops an infection at the site of the surgical incision. The patient visits the surgeon at her office. The surgeon inspects and cleans the wound, changes the patient's dressings and administers antibiotics.

For a private payer following CPT guidelines, the surgeon may report an E/M service (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier -24 appended. The modifier indicates that the service is not included in the global fee for the initial surgery, Appell says. But for a Medicare payer, you must count the office visit as a part of the surgical package, and you cannot file a claim for additional reimbursement.

Coding Example B: Three weeks following surgery, the surgeon readmits the patient to the hospital for wound abscess but does not return the patient to the operating room. Once again in this case, you may not report a separate service for Medicare, even though the surgeon re-admitted the patient. CMS guidelines specify that when the surgeon readmits the patient within the global period of the original surgery for complications of the original surgery, you cannot charge for the readmission.

But for payers following CPT guidelines, you may 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.

Coding Example C: The patient from Example A has a more severe infection, reaching deeper into the surgical wound. To treat the infection, the surgeon returns the patient to the OR for debridement (for example, 11000, Debridement of extensive eczematous or infected skin; up to 10% of body surface). In this case, you should report 11000-78 for both Medicare and private payers, Allen says.
 
Don't Expect Total Reimbursement With -78

When you're filing claims with modifier -78, don't expect to receive 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 because these are included in payment for the original procedure, Bucknam says. Modifier -78 claims are generally reimbursed 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. Rather, all services fall within the global period of the original procedure.