Otolaryngology Coding Alert

If you're treating Medicare and private payers the same, you're losing payments

If you-re including your ENT's care for postsurgical complications in the global surgical package of the primary procedure every time, you-re missing out on legitimate revenue.

To determine if you deserve additional reimbursement, ask yourself two questions:

Question 1: Who's the Payer?

Medicare treats postoperative complications differently than insurers who follow CPT guidelines. Although both CMS (Medicare) and CPT (AMA) guidelines indicate that the global surgical package includes -typical- postsurgical care, the two sources differ on what qualifies as typical--which means you must differentiate your claims depending on the payer you are billing.

-Basically, Medicare requires that a complication must be significant enough to warrant a return to the operating room before you may report a separate procedure,- says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery in New York City. 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 less strict,- Sandhusen says, -and you may report some postoperative services during the global period, including treatment of infection, that the ENT provides in the office.- This means, for instance, that you could collect an additional $80 from private payers for a level-four established patient visit (99214) to deal with a patient's postoperative infection.

Here's the bottom line: If treatment of a post-operative infection (for instance) requires that the ENT return the patient to the operating room, you may report the procedure for either Medicare or private payers. If the ENT can treat the infection in his office or admits the patient for IV antibiotics, however, you may only file a claim for those payers that follow CPT guidelines by using modifier 24 on the E/M service.

Question 2: Did the ENT Go Back to the OR?

For both Medicare and private payers, you-ll have to append a modifier to the appropriate CPT code to describe the ENT's treatment of the postsurgical infection. -If the ENT 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.

CMS and CPT agree: You should use modifier 78 to indicate a return to the operating for both private and Medicare payers. CMS guidelines specifically note that modifier 78 -indicate[s] that the service necessary to treat the complication required a return to the operating room during the postoperative period.-

Turn to 24 for Unrelated E/M Services

To gain reimbursement from private payers for unrelated, in-office postoperative evaluations during the global period, you should 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.

-Because payers following CPT guidelines do not consider postoperative infections as necessarily -related- to the initial surgery, you can charge for an E/M service. However, you should use modifier 24 to tell the payer that the E/M service is distinct and not a part of the global surgical package,- Bucknam says. And, you should link the ICD-9 for the post-op complication to the E/M service code.

Remember: You can't charge separately for in-office post-op care for Medicare payers.

Learn more: For complete information on modifier 24, see -Pick the Correct E/M Modifier Every Time: Here's How- of the November 2005 Otolaryngology Coding Alert.

3 Examples Give You the Idea

Look at the following scenarios to help guide your modifier 78, postsurgical complications coding:
 
Coding example A: A 6-year-old patient undergoes a tonsillectomy (42825, Tonsillectomy, primary or secondary; under age 12). The procedure has a 90-day postoperative period.

Five days after the surgery, the patient bleeds so profusely that the otolaryngologist must control the oral hemorrhaging (42962, Control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; with secondary surgical intervention) in the operating room.

In this case, the hemorrhage control is a -complication- of the tonsillectomy. Because the complication occurred during the global period of the original procedure, and because the ENT had to return the patient to the operating room, you should append modifier 78 to 42962.

Coding example B: A young tracheostomy patient must have a post-fistula trach change during the 90-day global period of 31610 (Tracheostomy, fenestration procedure with skin flaps). Because the patient is difficultto control, the ENT opts to perform the procedure in the OR with anesthesia.

CPT does not contain a particular code for this scenario, so you will have to report 31899 (Unlisted procedure, trachea, bronchi) with supporting documentation. You should still, however, append modifier 78 to indicate that the second procedure was a complication of the tracheostomy.

Coding example C: Three weeks following surgery, the ENT readmits the patient to the hospital for wound abscess, which requires IV antibiotics, but does not return the patient to the operating room.

In this case, you may not report a separate service for Medicare, even though the ENT readmitted the patient. CMS guidelines specify that when the ENT 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 following CPT guidelines, you may report an appropriate admission code (for example, 99221, Initial hospital care, per day, for the evaluation and management of a patient ...) appended with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).

Don't Expect Total Reimbursement With 78

When you-re filing claims with modifier 78, don't expect to receive 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 are generally reimbursed at 65-80 percent of the full fee schedule value, depending on the payer. However, the global period for the original surgery is not -reset- by the return to the operating room.