Otolaryngology Coding Alert

Medicare will only allow return to OR with 78

CPT rules allow you to report an E/M service with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) if the surgeon evaluates the patient for a complication during a previous procedure's global.

-Because payers following CPT guidelines do not consider postoperative complications as necessarily -related- to the initial surgery, you can charge for an E/M service. However, you should use the 24 modifier to tell the payer that the E/M service is distinct and not a part of the global surgical package,- says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.

Diagnosis tip: When reporting a service with modifier 24, you should use an ICD-9 code that describes the new problem (for instance, post-op infection). Do not use the same diagnosis that prompted the original procedure.

Medicare Plays by Different Rules

Medicare payers (and some private payers) do not follow CPT's global package guidelines and will only pay for treatment of complications during a global period if the complication results in a return to the operating room (OR), says Susan Allen, CPC, compliance coder with JSA Healthcare in St. Petersburg, Fla.

Example: Several weeks following excision turbinate (for example, 30130, Excision turbinate, partial or complete, any method) the patient develops an infection at the site of the surgical incision. During an office visit, the surgeon inspects and cleans the wound, changes the patient's dressings and administers antibiotics.

For a private payer following CPT guidelines, you may report an E/M service (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 24 appended. You should include a diagnosis of 998.5x (Postoperative infection). The modifier and distinct diagnosis indicate that the payer should not include the service as a part of the initial surgery's global fee.

For a Medicare payer, however, you must count the office visit as a part of the surgical package, and you cannot file a claim for additional reimbursement.

Bottom line: Know whether your payer follows CPT or CMS guidelines before you report a postoperative complication service with modifier 24.

Turn to 78 for Complications Treated in OR

If the surgeon must treat the patient in the OR for complications during the global period, you may report the treatment separately by appending modifier 78 (Return to the operating room for a related procedure during the postoperative period) to the appropriate CPT code, Allen says. This applies to both Medicare and private payers.

Example: The patient in the above example has more severe infection, reaching deeper into the surgical wound. To treat the infection, the surgeon returns the patient to the OR for incision and drainage (10180, Incision and drainage, complex, postoperative wound infection). In this case, you should report 10180-78 for both CPT and CMS payers. Again, you should attach a diagnosis of 998.5x to describe the postoperative infection.