Neurosurgery Coding Alert

Question: An L4/5 hemilaminectomy and diskectomy (63030, laminotomy [hemilaminectomy], with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically-assisted approach]) was performed on a patient who was then discharged on the third day of recovery. The patient was readmitted on the seventh day with a wound infection. Can the history and physical be billed or is it covered under the global service?

Ravi Goyal, MD
Bay City, Mich.

Answer: Heidi Stout, CPC, coding and reimbursement manager at University Orthopaedic Associates, New Brunswick, N.J., says, according to Medicares global surgery policy (S-99A), the Medicare approved amount for surgical procedures includes all additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room.

In the scenario described above with a readmission to the hospital seven days post surgery with a wound infection, Medicare would not reimburse for any medical services rendered, therefore, reporting an evaluation and management code would result in a denial.

CPT Assistant notes that the global package includes normal uncomplicated follow-up care, therefore, this may be billed to other payers with the -24 modifier (unrelated evaluation and management service by the same physician during a postoperative period). If the neurosurgeon takes the patient to the operating room for an incision and drainage or debridement of the wound, the appropriate CPT code for the secondary surgical procedure may be reported with modifier -78 (return to the operating room for a related procedure during the postoperative period) appended to the code.