Orthopedic Coding Alert

Know when not to follow CMS guidelines

If you include postsurgical infection care in the global surgical package of primary procedures, you could be missing out on an important source of legitimate revenue if you're billing private payers.

To determine whether you deserve additional reimbursement, you should ask yourself two important questions, our experts say.

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

"Basically, Medicare requires that a complication must be significant enough to warrant a return to the operating room before you may report a separate procedure," says Susan Allen, CPC, CCS-P, coding manager and compliance officer for Florida Spine Institute in Clearwater, Fla. CMS guidelines specifically state, "When the services described by CPT codes as complications of a primary procedure require a return to the operating room," you may report a separate procedure, according to Chapter 1 of the National Correct Coding Initiative (NCCI).

But CPT guidelines are less strict, and you may report some postoperative services during the global period, including infection treatment, that the orthopedic surgeon provides in the office. This means, for instance, that you could collect an additional $80 from private payers that follow CPT guidelines for a level-four established-patient office visit (99214) to deal with a patient's postoperative infection.

Here's the bottom line: If treating a postoperative infection requires the orthopedic surgeon to return the patient to the operating room, you may report the procedure to either Medicare or private payers. If the orthopedic surgeon can treat the infection in his office, however, you may only file a separate claim for those payers that follow CPT (not CMS) guidelines.

For both Medicare and private payers, you'll have to append a modifier to the appropriate CPT code to describe the orthopedic surgeon's treatment of the post-surgical infection.

"If the surgeon is returning to the operating room during the global surgical period of a previous procedure, the correct modifier is -78 (Return to the operating room for a related procedure during the postoperative period)," says Julia A. Appell, CPC, a surgical coder in South Bend, Ind. And, modifier -78 "indicat[es] that the service necessary to treat the complication required a return to the operating room during the postoperative period," according to CMS guidelines. Using modifier -78 to indicate a return to the operating room applies to both private and Medicare payers.

Before private payers will reimburse in-office postoperative infection treatment during the global period, you must append modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M service code, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb. "Because payers following CPT guidelines do not consider postoperative infections as necessarily 'related' to the initial surgery, you can charge for an E/M service. However, you should use the -24 modifier to tell the payer that the E/M service is distinct from and not a part of the global surgical package."

Some coders question whether a postoperative infection is actually unrelated to the surgery, arguing that the patient wouldn't have an infection if he hadn't had surgery. But if you show the payer that the reason for the initial surgery and the reason for postoperative care differ (that is, they require different diagnoses), the procedures qualify as distinct from one another.

"The initial surgery and postoperative infection care would have different diagnosis codes, so that justifies the use of the -24 modifier as 'unrelated,'" says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.

The definition of modifier -24 (as outlined in the December 1992 CPT Assistant) offers further evidence that you should treat postoperative infections as independent of the surgery, at least for payers that follow CPT guidelines. "Modifier -24 is used when a physician who has provided a surgical service related to one problem, now provides an evaluation and management service unrelated to the problem requiring the surgery, during the period of follow-up care for the surgery," CPT Assistant states.

"Note," Sandham says, "that the phrase stresses that the care is unrelated 'to the problem requiring the surgery,' not to the surgery itself."

Therefore, if the surgeon provides wound care for an infection at the site of a previous fracture repair, for instance, he is dealing with a different "problem" than the fracture (the fracture was the reason for the patient's initial surgery.)

Don't forget the diagnosis: In all cases, you should link an appropriate diagnosis, such as 998.59 (Other postoperative infection), to any CPT codes you report for treating the infection.

Take a look at the following scenarios to help guide your postsurgical infection billing:

Coding Example A: Several weeks following diskec-tomy (for example, 63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace), the patient develops an infection at the site of the surgical incision. The patient visits the orthopedic surgeon at her office. The orthopedist inspects and cleans the wound, changes the patient's dressings and administers antibiotics.

For a private payer following CPT guidelines, the orthopedic surgeon may report an E/M service (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier -24 appended.

The modifier indicates that the service is not included in the global fee for the initial surgery, Appell says. For a Medicare payer, however, you must count the office visit as part of the surgical package, and you cannot file a claim for additional reimbursement.

Coding Example B: Three weeks following surgery, the orthopedist readmits the patient to the hospital for a wound abscess but does not return the patient to the operating room. Once again, you may not report a separate service to Medicare, even though the orthopedic surgeon readmitted the patient. CMS guidelines specify that when the orthopedist readmits the patient within the original surgery's global period for complications of the original surgery, you cannot charge for the readmission.

For payers following CPT guidelines, however, you should report an appropriate admission code (for example, 99221, Initial hospital care, per day, for the evaluation and management of a patient ...) with modifier -24 appended.

Coding Example C: The patient from Example A, above, has a more severe infection, reaching deeper into the surgical wound. To treat the infection, the orthopedic surgeon 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 to both Medicare and private payers, Allen says.

When you file claims with modifier -78, don't hold your breath for the full fee schedule reimbursement amount. Procedures that you bill with modifier -78 include only the "intraoperative" portion of the service (payers make no payment for pre- and postoperative care), Bucknam says, and insurers generally reimburse them at 65-80 percent of the full fee schedule value, depending on the payer. But when you append modifier -78, you do not incur a "new" global period.