Neurosurgery Coding Alert

Question: A patient developed an infection several days after surgery and came to the office for an evaluation. Is this visit considered part of the global period, or can we report the service with a modifier?

Tennessee Subscriber

Answer: A general evaluation of the infection would be part of the global period and not separately billable. If the surgeon completed another procedure during the evaluation, however, you might be able to code that care.

Example: The physician performs irrigation and drainage around the infected area. You still can't report an E/M code because of the global period, but could submit the appropriate incision and drainage (I&D) code (such as 10180 [Incision and drainage of pilonidal cyst; simple]) if the procedure is performed in the operating room. Append modifier 78 (Unplanned return to the operating room/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to 10180 to show the I&D is related to the original surgery.