Neurosurgery Coding Alert

Question: A patient undergoes a parietal craniotomy to excise a brain tumor. Several weeks after surgery, signs of infection appear, including redness and pus at the suture line. The neurosurgeon performed an E/M to prescribe antibiotics. Should this be part of the global period? Also, the neurosurgeon took the patient back to the OR to perform debridement. What should my claim entail?

Georgia Subscriber

Answer: If this is a non-Medicare patient, depending on the payers rules, you may be able to report E/M services (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient &) with modifier 24 (Unrelated evaluation and management service by the same physician during a  postoperative period) appended. Because the surgeon must determine what antibiotics are warranted, which type, and how long they should be given, you may consider these E/M services as separate from the typical postoperative global care -- but this is only for non-Medicare patients.

Note: For Medicare patients, you should include the postoperative care in the global fee for 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma).

For the return to the OR for debridement, look at 11040-11044. For instance, if the infection spread beyond the suture to include the surrounding skin and subcutaneous tissue, you should report 11042 (Debridement; skin, and subcutaneous tissue) for Medicare and non-Medicare patients. In this particular case, the best diagnosis is 998.59 (Other postoperative infection).

A less common diagnosis is wound dehiscence (998.3, Disruption of operation wound). You would code this with 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated). Similarly, you would report the incision and drainage of post-op wound infection with 10180 (Incision and drainage, complex, postoperative wound infection).

Dont forget: When returning to the operating room during the global period, you must also append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to the appropriate procedure code (such as 11042-78 in the debridement example, above).