Neurosurgery Coding Alert

Question: Following low-back surgery, we had to readmit the patient for a wound abscess. Can we charge for the readmission and daily care?


Arizona Subscriber

Answer: If the surgeon readmits the patient during the global period of the original surgery for the same problem that prompted the original surgery, you cannot charge for the readmission or hospital visits.

Medicare considers an abscess at the operative site to be part of the "same problem," whereas CPT provides some leeway for such complications because they represent a different diagnosis and are beyond the scope of normal follow-up care.

If, however, the patient's condition and the treatment of the abscess require a trip o the operating room, you may report the procedure performed and append modifier -78 (Return to the operating room for a related procedure during the postoperative period) no matter who the payer is.

If the surgeon readmits the patient after the global period of the original surgery, you may report the appropriate level of service for the hospital admission and subsequent care.