Orthopedic Coding Alert

Hint: Look to global period and modifiers for your solutions.

You could be sabotaging your claims for post-op infections if you aren’t well versed on individual payers’ global policies and unsure of what modifiers to append. Here are three common scenarios to facilitate better reporting of postsurgical infection billing:

Coding scenario 1: Several days following an open repair of distal fibular fracture, 27792 (Open treatment of distal fibular fracture [lateral malleolus], includes internal fixation, when performed), the patient develops a stitch abscess with drainage at the site of the incision. The patient schedules an unplanned visit to the office of the orthopedic surgeon. The surgeon prescribes antibiotics and a follow-up.

For a private payer that follows the AMA CPT^® guidelines for post-operative complications, you would report an E/M service (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) appended with modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period), if the payer requires you to do so. The modifier is usually needed because any service in the global is automatically denied within payer software systems.

Tip: Use the abscess as the diagnosis, not the reason for the open repair. You report this with code T81.4XXA (Infection following a procedure, initial encounter). The abscess diagnosis shows the “unrelated” reason for the E/M service. The modifier indicates that the payer does not include the service in the initial surgery’s global fee. Had the patient been covered by Medicare, however, the office visit counts as a part of the global package, and you cannot file an additional claim. Medicare would only pay for treatment of the post-op infection if the surgeon had to take the patient to the operating room to perform incision and drainage of the abscess, experts say.

Coding scenario 2: A week following surgery, the surgeon readmits the patient to the hospital for IV antibiotics but does not take the patient back to the operating room. Once again, in this case, you may not report a separate service to Medicare, even though the orthopedist readmitted the patient. CMS guidelines specify that when the physician readmits the patient within the original surgery’s global period for complications of the original surgery, you cannot charge evaluation and management services for the readmission or for other E/M services if another physician admits the patient.

“But for payers not following CMS guidelines, and follow the AMA CPT^® guidelines, you may be able to 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,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

Coding scenario 3: The patient from example 1, who developed a stitch abscess, goes on to require an incision and drainage in the OR, for example, 10180 (Incision and drainage, complex, postoperative wound infection).

In this case, you should report 10180-78 for both Medicare and private payers. Don’t forget the diagnosis to consider is T81.4XXA, to any CPT^® codes you report.  “CMS pays at a reduced rate for surgical services in the postoperative global period which are related complications of the original procedure. The reduction is driven by the overlap of pre- and postoperative services already paid for in the original procedure,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.