Neurosurgery Coding Alert

CMS guidelines 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." You may, however, report critical care services separately (see "Understand Global Periods and Avoid a World of Hurt," Neurosurgery Coding Alert, April 2003, for more information).

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 undergone parietal craniotomy for brain tumor excision (61510, Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) shows signs of infection along the suture line. The surgeon must examine the potential infection and determine if antibiotics are warranted and if so, which type, for how long and in what fashion to deliver them.

"This 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 who observe CPT conventions, 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, 61510) 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 neurosurgeon 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 (see Neurosurgery Coding Alert, April 2003, for more information).

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 it required a 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.

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. Absent guidelines to the contrary, you may assume your payer follows CPT conventions. But 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.