Ob-Gyn Coding Alert

Total abdominal hysterectomy (58150) is a common gynecological surgery that requires postsurgical follow-up. For complications following surgery, coders need to know when to use modifiers, which modifiers to use, and which payers will reimburse for postoperative procedures within the global period.

Contacting individual payers before submitting obstetric and gynecological surgical package claims (56405-59899) will help you sort out the appropriate CPT or Medicare definition to use for a global period. It is particularly important that you determine early on what your payers guidelines are on the lengths of postoperative services because CPT and Medicare definitions for surgical packages differ markedly.

Also, third-party payers may have their own guidelines regarding what constitutes an appropriate length of time for the global period or follow-up for surgical services and procedures. The global period for major surgeries can range from 21 days to as much as 90 days of follow-up for the same procedure.

Coding Within the Global Period

If the postoperative procedure or service does not fall within the global period, the ob/gyn is entitled to independently claim reimbursement under both CPT and Medicare guidelines. But with hysterectomies, most complications occur within the first 10 days following surgery, and 58150 (total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or withoutremoval of ovary[s]) has a 90-day global period. For procedures occurring within the global period, an in-office procedure may be considered a normal complication of the initial surgery.

For example, a patient with a wound infection a complication of the hysterectomy returns to see the ob/gyn within the global period and is treated during the office visit. The E/M visit to treat the infection may be considered part of the surgical global package and any procedure that might be performed (e.g., wound cleaning or repacking) treated as a normal complication of surgery. While a few carriers will pay for this visit as an E/M charge, Medicare and the majority of private carriers will not consider this a billable service.

A lot of physicians dont pursue charges like these because they consider them part of taking care of the operation, says Philip Eskew Jr., MD, medical director of women and infant services at St. Vincent Hospital in Indianapolis. Eskew adds that a postoperative wound infection generally doesnt require a lot of physician time to treat. However, Eskew contends that if complications are significant and require a return to surgery or other more involved procedures, it is appropriate to seek reimbursement.

Know the Global Ground Rules

Both Medicare and CPT have criteria for what is included in the surgical package. CPT says the surgical package includes only the following elements:

The surgical procedure

Local or topical anesthetic or metacarpal or digital anesthetic blocks

Normal, uncomplicated follow-up (postoperative)care.

The CPT surgical package definition applies to all codes in the surgery section that are not starred procedures. This means that all the components are included in a single charge for the surgical procedure. From a strict CPT standpoint, the global package consists only of normal, uncomplicated follow-up care.

HCFAs approach contradicts CPTs, which limits the global package to normal, uncomplicated follow-up care. Medicares global package for major surgery includes all post-operative visits, supplies, and post-operative pain management for 0-10 days following surgery for minor procedures and endoscopies, and for 90 days following major surgeries, according to the Medicare Carriers Manual (MCM). All services related to complications of the surgery that do not require a return to the operating room are included in the surgery global fee. This includes simple procedures performed at bedside or in a treatment room of your office. Refer to section 4821 of the MCM for the complete guidelines to Medicares global package for major surgeries.

Complications in the Office

For a severe wound infection following a hysterectomy, practices might attempt to charge for an E/M visit that may include prescriptions for antibiotics, wound cleaning, repacking, etc. This would take place in the office, and a private carrier may reimburse for the visit. However, under no circumstances will Medicare pay for postoperative care, unless it takes place in the operating room.

If the hysterectomy patient comes in for a post-operative check, and she has a bacterial infection of the vagina, the physician will perform and bill for 57150* (irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease), appending modifier -79 (unrelated procedure or service by the same physician during the postoperative period) to the irrigation code.

For more involved postoperative complications that require a CPT service, coders should use modifier -79 or
-78 (return to the operating room for a related procedure during the postoperative period). The physician may need to indicate that a procedure or service during the postoperative period was unrelated to the original procedure.

The -79 modifier starts a new global period for the new procedure. In the case of 57150, a starred procedure, the global period is only one day. But if the patient showed up for her postoperative checkup and the physician discovered a Bartholins gland cyst, and performed a marsupialization of Bartholins gland cyst (56440), modifier -79 would be appended to the 56440. This code has a 10-day global period, which would go into effect when this second (unrelated) surgery was performed.

In either case, coders can bill for and should anticipate the full payment for the second surgery.

Return to the Operating Room

Modifier -78, on the other hand, cannot be used unless the patient returns to the operating room. However, it does not revise or start a new global period as -79 does. Also unlike modifier -79, modifier -78 pays for the intraoperative period only, which means the reimbursement for the surgery code will be greatly reduced from the full fee.

If a posthysterectomy patient reports with unexplained pelvic tenderness and blood oozing from the wound, the physician would return her to the operating room, open the incision, check for and repair any bleeders, remove clots and reclose the original surgical site. Using 49002 (reopening of recent laparotomy), the coder would report the second procedure with the -78 modifier. The -78 modifier signifies to Medicare and other payers that the place of service was the operating room, and it is the only modifier with which Medicare will pay for postoperative procedures within the global surgical package period.

Practices that knowingly or unknowingly bill for bundled services included within the global period may find themselves at the very least closely monitored, and at the worst, subject to an investigation for fraud because the reimbursement filing would be considered a deliberate attempt to double-bill the payer. Check with your top payers to be sure you understand their definitions and expectations for a global period. If you start nickel and diming for every aspect of postoperative care, your carriers are going to grow suspicious of your motives, Eskew adds.