Orthopedic Coding Alert

Question: We performed a total hip replacement (27130) and saw the patient three weeks later for a postoperative infection. The orthopedic surgeon performed an incision and drainage in the office and we reported 10180 for that. Medicare paid the claim but then asked for our records shortly afterward. Before I submit the records, I want to double-check whether we should have appended modifier 79 to 10180 for the I&D service. Is that applicable on this claim?


Connecticut Subscriber
Answer: Although both CMS 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.

Medicare requires that a complication must be significant enough to warrant a return to the operating room before you may report a separate procedure. 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.

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. You-ll report the appropriate I&D code (such as 10180, Incision and drainage, complex, postoperative wound infection) to those payers that allow you to bill the post-op infection in the office during the global period. You should append a modifier, such as 79 (Unrelated procedure or service by the same physician during the postoperative period), to 10180 if the surgeon feels that the service is unrelated to the original surgery.

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.
 
Because you treated a Medicare patient and did not return the patient to the operating room, no modifier applies to your claim. Your payer most likely realized its mistake, and once the claims reviewer reads that the physician performed the I&D in the office, you will have to pay the carrier back the reimbursement amount  for 10180.