Orthopedic Coding Alert

Payers and modifiers deserve special attention.

You could be forfeiting legitimate reimbursement if you’re including postsurgical infections in the global surgical package of a primary procedure. The billing may seem difficult, as the payer preferences may differ. Use the expert advice that follows for flawless reporting of postoperative infections.

Tip 1: Distinguish Between Medicare and Non-Medicare Patients

Medicare treats postoperative complications, including infections, differently than insurers who follow CPT^® guidelines. Although both CMS (Medicare) and CPT^® guidelines indicate that the global surgical package includes "typical" postsurgical care, the two sources differ regarding what qualifies as typical -- which means you must differentiate your claims depending on which payer you are coding for.

Medicare requires that a complication be significant enough to warrant a return to the operating room before you may report a separate procedure in the global period. In fact, CMS "Correct Coding" 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. "On the other hand, incision and drainage of a postoperative wound in your office or local wound care with debridement in the office would not be separately reportable within the global period according to CMS guidelines," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

AMA CPT^® is very clear on complications in the post-operative period. CPT^® states the following in the front of the surgical section (page 58 of 2013 CPT^® Professional from the AMA): "Complications, exacerbations, recurrences, or the presence of other diseases or injuries requiring additional services should be separately reported." This is found in the second column under the heading of "Follow-Up Care for Therapeutic Surgical Procedures." You’ll find similar instructions for "Follow-Up Care for Diagnostic Procedures."

Remember: "Keep in mind that the separate service may not necessarily have to be a procedure. For example, an E&M service of higher level may be considered to describe local wound care that increases the complexity of a postoperative visit for managing the unexpected complication," says Przybylski.

"Some non-Medicare payers may follow AMA CPT^® guidelines and allow you to report services for treating postoperative complications that CMS typically bundles into the global period, including infection treatment that the surgeon provides in the office," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia. This means, for instance, that you may be able to collect payment from private payers for a level-three or four established patient visit (99213 or 99214) to deal with a patient’s postoperative infection depending on the documentation.

The bottom line: If treatment of a postoperative infection requires the surgeon to return the patient to the operating room, you should report the procedure to either Medicare or private payers. "If the surgeon can treat the infection in his office, however, you may be able to file a claim only to those payers that do not follow CMS guidelines," Pohlig says. "You should query the payers in writing beforehand to ensure proper coding and billing compliance."

Private payers do not have clear-cut rules, Pohlig notes. In fact, many of their coding guidelines are contractual. "What may be negotiated for one physician group may not be included in another group’s contract," she says.

Tip 2: Decide What Modifier to Use

For both Medicare and private payers that recognize them, you’ll have to add a modifier to the appropriate CPT^® code to describe the surgeon’s postsurgical infection treatment. 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). Modifier 78 "indicates that the service necessary to treat the complication required a return to the operating room during the postoperative period," according to CMS guidelines. You should use modifier 78 to indicate a return to the operating room for both private and Medicare payers.

"For private payers that reimburse separately for in-office or bedside 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, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash. Code the diagnosis for the infection for this visit, not the surgery. "Since the global period includes all of the routine postoperative visits within that period, a separately identifiable E&M service in the global period must be attributed to a separate diagnosis from the one(s) used for the surgical treatment," says Przybylski.

You may also have to perform a procedure, such as incision and drainage of a skin wound infection (10060 or 10061), in the office or bedside without a return to the OR for a non-Medicare payer. If so, you must append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) on the procedure code for an unrelated procedure. Although it appears that the procedure is related to the global, this procedure is being done specifically for the infection, not for the original diagnosis that led to the original surgery.

Don’t Expect Total Reimbursement With 78

When you file claims with modifier 78, don’t expect to collect the full fee schedule reimbursement amount. Procedures billed with modifier 78 include only the "intraoperative" portion of the service (no payment is made for pre- and postoperative care), 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. "This is in contrast to planned staged surgery, reported with modifier 58, in which the global period extends after the second staged procedure," says Przybylski.