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, [...]