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. Question 1: Who's the Payer? 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. Question 2: Which Modifier Should I Append? 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. Use -24 for In-Office Infection Treatment Before private payers will reimburse in-office postoperative infection treatment during the global [...]