Otolaryngology Coding Alert

Question: I’m seeing more denials of claims for post-op complications that require hospitalization because of dehydration, bleeding, etc. We often get other denials when we appeal. Most of the claims are for Medicare or Blue Cross. Is there anything we can do? 

Oklahoma Subscriber

Answer: Hospitalization has no bearing on whether you’ll be paid for services related to postoperative complications for Medicare patients. Medicare will not pay for post-op complication unless it involves a return to surgery. 

As for Blue Cross (and other private insurers), they should pay for the service unless they have guidelines stating that they follow Medicare rules. Submit the claim with the complication as the primary diagnosis instead of the diagnosis related to the reason for the original surgery. Append modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) to the codes for any procedures and modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to the E/M service leading to the post-op care. If the E/M service and procedure related to the post-op complication are performed on the same day, you’ll also need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code.