Neurosurgery Coding Alert

For Medicare, you must meet 2 conditions for correct billing

Medicare treats payment for post-op complications, such as infections, differently than insurers that follow CPT guidelines. So, which rules should you follow?

Although both CMS (Medicare) and CPT guidelines indicate that the global surgical package includes "typical" postsurgical care, the two sources disagree on what qualifies as typical -- which means you must differentiate your claims depending on the payer you are billing.

The difference in a nutshell: To report a separate code to Medicare payers for dealing with a complication within a procedure's global period, the circumstances must meet two conditions:

1. Treatment of the complication must be required at a different session from the original procedure. If the physician can treat the complication during the initial procedure (for instance, control of bleeding or lysis of adhesions), Medicare bundles the complication care to the global surgical package, says Nancy Reading, RN, BS, CPC, director of educational services for the American Academy of Professional Coders.

Here's what CMS says: "When a complication described by codes defining complications arises during an operative session - a separate service for treating the complication is not to be reported," according to CMS guidelines in the national Correct Coding Initiative (CCI). CCI guidelines also state, "Codes describing services necessary to address complications - should not be submitted for services rendered at the same surgical session that resulted in the complication. If performed in conjunction with the primary procedure, it would be included in the primary - procedure."

As an example, control of bleeding is always an included service if it occurs during the same session as the original procedure, Reading says. If the physician must perform control of bleeding at a later session, with a return to the operating room, you may be able to report it separately (see condition 2).

2. Treatment of the complication must require a return to the operating room. If the physician can treat the complication without a return to the operating room, Medicare bundles the treatment into the initial procedure's global surgical package.

Example: Several weeks following parietal craniotomy for brain tumor excision (61510, Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma), the patient shows signs of infection along the suture line during a follow-up visit in the office. The physician inspects and cleans the wound, changes the patient's dressings and administers antibiotics.

In this case, because the physician was able to treat the post-op complication (infection) without a return to the operating room, the visit and treatment are included in the craniotomy's global surgical package and are not separately reportable (or payable), Reading says.

In another case: Three weeks following surgery, the physician readmits the patient to the hospital for wound abscess but does not return the patient to the operating room.

Once again in this case, you may not report a separate service for Medicare -- even though the physician re-admitted the patient.

CMS guidelines specify that when the physician readmits the patient within the original surgery's global period for complications of the original surgery, you cannot charge for the readmission.

Remember: Unless complications require a return to the operating room, you can't separately report related post-op care.

The Right Modifier Matters

When the physician does return a patient to the operating room to deal with a complication during the global period of the original surgery, you-ll have to 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 whatever services the physician reports for treating the complication, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Children's University Medical Group (CUMG) Compliance Program.

How Medicare says it: CCI guidelines dictate, "When the services described by CPT codes as complications of a primary procedure require a return to the operating room, they may be reported separately; generally, due to global surgery policy, they should be reported with modifier 78 indicating that the service necessary to treat the complication required a return to the operating room during the postoperative period."

Example: In a case similar to that cited above, a patient develops an infection six weeks after parietal craniotomy for brain tumor excision (61510). In this case, the infection is more severe, reaching deeper into the surgical wound. To treat the infection, the physician returns the patient to the OR for debridement (for example, 11000, Debridement of extensive eczematous or infected skin; up to 10% of body surface).

In this case, you should report 11000-78.

Here's why: The care required to deal with the post-op infection both occurred at a different session from the original procedure and required a return to the operating room (as described by modifier 78)

ICD-9 tip: Don't ignore your diagnosis coding, Bucknam says. The reason for the return to the operating room is not the same as the reason for the original surgery. In the above case, for instance, you should link an appropriate diagnosis, such as 998.59 (Other postoperative infection), to 11000.

More to come: In following months, look to Neurosurgery Coding Alert for more information on reporting services during another procedure's global period, including proper use of modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) for Medicare and non-Medicare payers, as well as how to report "staged" procedures.

If you want to report separate codes for care of complications to Medicare, be sure that your claim meets all of the following conditions:

- Treatment of the complication occurs within the global period of the original procedure (if care takes place outside the original procedure's global period, you may report the services as usual).

- The complication must be handled at a separate session from the original procedure.

- Effective treatment of the complication must require a return to the operating room.

- Append modifier 78 to any procedure codes you report that constitute treatment of complications with a return to the operating room during the global period.