Orthopedic Coding Alert

With routine orthopedic surgeries like total hip (THR) and knee (TKR) replacements, patients often encounter complications while still under the global care period for the surgery. These can be the result of additional injury or accident, infection or an unforeseen problem with the prosthetic device. And these complications can run the gamut from problems clearly related to the original procedure to other injuries or procedures that seem to have nothing to do with the original surgery or operative site. Orthopedic coders must know the difference between what Medicare and commercial payers consider a postoperative complication to be properly reimbursed for their services.

A major surgery has a 90-day global period. For example, if a patient undergoes a total hip replacement (27130, arthroplasty, acetabular and proximal femoral prosthetic replacement [total hip replacement], with or without autograft or allograft), this procedure has a 90-day global period that includes preoperative visits after the decision to operate, intraoperative services, routine followup care, postoperative visits, pain management, supplies and miscellaneous services (e.g., removal of casts and splints).

For example, the patient with the total hip replacement (THR), in the course of her recovery from the THR, falls and breaks her wrist and returns to the same orthopedic surgeon to have her wrist set. Because the new procedure is unrelated to the hip surgery, the operating surgeon (OS) can bill for the wrist fracture using the appropriate code (e.g., 25620, open treatment of distal radial fracture [e.g., Colles or Smith type]), but must add modifier -79 (unrelated procedure or service by the same physician during the postoperative period).

Whats Really Included?

The above example is a fairly straightforward example of non-routine followup care within a global surgical period. But at the heart of the confusion over postoperative complications is whether the complication is related to the original surgery (and by whose definition of related) and whether postoperative complications are in fact covered by the global surgical period. Many coders have been working for years under the impression that any complications related to surgery are always billable separately from the surgery, as long as they use the appropriate modifier.

Trina Buxton Flores, office manager at Northern Colorado Orthopedic Associates in Fort Collins, Colo., is one of many ortho coders who have been billing for postoperative complications. I had always assumed, Flores says, that postoperative complications were outside of routine followup care, and therefore not included in global. Flores usually codes in-office post-op complications with modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period), and also disputes the assertion that subsequent cast applications, supplies and braces, etc., postsurgery are included and not separately billable.

Others in the orthopedic field, including Richard Cunningham Jr., MD, of Tennessee Orthopaedic Clinics in Knoxville, Tenn., agree that the global surgical period covers only routine, normal followup. Something like a dislocated hip prosthesis following a total hip replacement (27130, arthroplasty, acetabular and proximal femoral prosthetic replacement [total hip replacement], with or without autograft or allograft) is not normal routine followup and is indeed a complication, Cunningham says. I would definitely code for that procedure using 27265 (closed treatment of post hip arthroplasty dislocation; without anesthesia) or 27266 (closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia).

Medicare vs. Commercial Insurers

Part of the confusion over postoperative complications lies in the difference between Medicares rules and commercial insurers rules. Under Medicares global surgery policy (see Medicare Carriers Manual, Part III), all postoperative complications that do not require a return trip to the operating room (OR) are considered components of the global surgical package. But commercial carriers will often pay for the treatment of post-op complications and the associated supplies regardless of whether there was a return to the OR.

Medicare states all postoperative complications are covered under the surgery code, while most commercial carriers consider all post-op complications as unrelated to the surgery, hence the use of the -79 modifier. For Medicare patients, the only time complications are separately billable is when they require a trip to the OR. So, even if a patient shows up in the emergency department (ED) with a related complication, as long as she is treated in the ED and not transferred to the OR, Medicare wont pay extra. And because physicians most often perform surgeries like total hip replacements on older patients, practices may find that most of these scenarios involve Medicare.

Orthopedic coding experts agree that when dealing with commercial carriers, postoperative complications and associated supplies should be submitted for billing.

What Constitutes a Complication?

The line between a postoperative complication and an unrelated procedure during the global period can often be fuzzy. To clear up some of the confusion, weve listed some potential scenarios and identified them as related or unrelated.

The following is a sample list of postoperative complications, which are billable to commercial carriers, but not to Medicare, when you append modifier -79 to the CPT code:

Post-op wound infection (998.59, other postoperative infection) requiring 10180 (incision and drainage, complex, postoperative wound infection).

Dislocation of prosthesis (996.4, mechanical complication of internal orthopedic device, implant and graft) treated in the emergency room with a closed reduction of a dislocated prosthesis using 27265.

Note: Although most commercial carriers consider post-op complications as unrelated, individual carriers may have different rules on the use of the modifier. Check with your carrier prior to submitting billing.

The following are examples of unrelated problems, the repair or correction of which are billable within the global period using the -79 modifier billable to both Medicare and commercial insurers:

During the post-op period of the total knee replacement, the patient develops a trigger finger (727.03, trigger finger [acquired]) and undergoes surgical release (26055, tendon sheath incision [e.g., for trigger finger]).

The THR patient falls and breaks her wrist due to losing her grip on a cane (813.41, Colles fracture) requiring 25600 (closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture of ulnar styloid; without manipulation).