Otolaryngology Coding Alert

Know when a payer's policies may not align with CMS.

Medicare's rules are clear-cut when it comes to complications following a surgical procedure. After confirming that the evaluation and management (E/M) visit and/or return to operating room (OR) occurred within a procedure's given global period, you can make a determination as to whether you can justifiably bill to Medicare.

"However, what many coders do not realize is that the AMA CPT® definition of what is included in the global surgical package is in conflict with Medicare's definition," says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, vice president at Stark Coding & Consulting LLC, in Shrewsbury, New Jersey. "AMA CPT® specifically states that complications and exacerbations are separately coded and billable during the global period," states Cobuzzi.

As a result, not all payers subscribe to Medicare's policies regarding physician services for complications within the global period. Specifically, when it comes to E/M services, you may, in fact, be able to bill out for an E/M visit within the global period for payers other than Medicare.

Read on for all the details you need on when, where, and how to bill for your provider's postoperative complication services.

Take a Look at Medicare's Policy

Most coders are conditioned to think that if a patient returns for an E/M visit for a surgical complication within the respective code's global period, the visit is non-billable. Consider Medicare's policies surrounding a procedure's global period:

According to Medicare's Global Surgery Booklet, the following service is included in the global surgery payment:

• All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications, which do not require additional trips to the OR.

Additionally, Medicare does not include the following service in the global surgery payment:

• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery.

If the patient's postoperative complications warrant a return to the OR, then you may separately bill with a modifier 78 (Unplanned return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a related Procedure during the postoperative period).

When to Consider Other Payer's Policies

Consider this example:

A 20-year-old patient experiences pain and presents to the emergency room (ER) 8 hours following a tonsillectomy for tonsillitis. After a workup examination, the surgeon diagnoses the patient with postoperative hemorrhage and subsequently performs a 42960 in the ER to stop the bleeding. A follow-up appointment is scheduled for one week. Can the provider bill out for this E/M visit and procedure?

In this scenario, assuming you are dealing with a Medicare patient, you may not bill for the (E/M) visit if the patient is presenting with symptoms related to the surgery. Since procedure 42821 (Tonsillectomy and adenoidectomy; age 12 or over) has a global period of 90 days, any related E/M service within that time period is considered an included component of the surgery.

However, if the patient is not a Medicare subscriber, your next step should be to confirm that the payer's policies do or do not follow Medicare's.

"If a payer is not Medicare and is silent as to whether they follow Centers for Medicare and Medicaid Services [CMS] rules, you may go on the assumption that they follow the AMA rules and bill out treatment for complications in the office, ED, or bedside," Cobuzzi details.

If the example above represents a Medicare patient, neither the E/M service nor the follow up 42960 (Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple) are separately payable because both the E/M and procedure are performed in the ER. Instead, they should be considered an inclusive component of the original surgery. If the patient had a follow-up procedure in the OR for a complication from the original surgery, then the procedure would be separately payable with modifier 78.

The postoperative E/M service and procedure would be billed to the non-Medicare payer who does not follow Medicare's global rules as follows:

• 9928x-24-25, J95.830 (Postprocedural hemorrhage of a respiratory system organ or structure following a respiratory system procedure)
• 42960-79, J95.830

As a general rule, if you are unsure, it's best to contact the payer to determine whether the payer follows by AMA or CMS guidelines. If a payer's guidelines do not specify one way or the other, there may be enough justification to bill out for a particular medical service within the global period.