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.-

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