Otolaryngology Coding Alert

If you're treating Medicare and private-payer claims the same, you could forfeit $80 or more per claim

If you include postsurgical infection care in your primary procedure's global surgical package every time, stop. You could be missing out on legitimate revenue. To determine whether you deserve additional reimbursement, ask yourself two questions:

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 bill.

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

But CPT guidelines are vague, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Some payers may allow you to report some postoperative services that CMS typically bundles into the global period, including infection treatment that the surgeon provides in the office, she adds. 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 otolaryn-gologist 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," she says.

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.

For both Medicare and private payers that recognize them, you'll have to add a modifier to the appropriate CPT code to describe the otolaryngologist'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)," says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues, in Fountain Valley, Calif. Modifier -78 "indicat[es] 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, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb. Code the diagnosis for the infection for this visit, not the surgery.

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 put modifier -79 on the procedure 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.

"Because payers who do not follow CMS guidelines may not consider postoperative infections as necessarily 'related'to the initial surgery, you may be able to charge for an E/M service. However, if recognized, you may use the -24 modifier to remind the payer that the E/M service is distinct and not a part of their global surgical package," Pohlig says.

Take a look at the following scenarios to help guide your postsurgical infection billing:

Coding example A: Several days following a tonsillectomy (for example, 42826, Tonsillectomy, primary or secondary; age 12 or over) the patient develops an abscess (475) at the site of the incision. The patient visits the otolaryngologist at her office. The physician prescribes antibiotics and a follow-up.

For a private payer that does not include this care in its surgical package, 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, if the payer requires you to do so. The modifier indicates that the payer does not include the service in the initial surgery's global fee. For a Medicare payer, however, the office visit counts as a part of the global package, and you cannot file an additional claim.

Coding example B: A week following surgery, the surgeon readmits the patient to the hospital for IV antibiotics but does not return the patient to the operating room. Once again in this case, you may not report a separate service to Medicare, even though the otolaryn-gologist 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 for the readmission.

But for payers not following CMS 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, Pohlig says.

Coding example C: The patient from Example A, who develops an abscess, requires an incision and drainage in the OR (for example, 42700, Incision and drainage abscess; peritonsillar). In this case, you should report 42700-78 for both Medicare and private payers. Don't forget the diagnosis to consider is 998.59 (Other postoperative infection), to any CPTcodes you report.

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.