Otolaryngology Coding Alert

Don't treat every infection as related to surgery, at least for private payers

Before deciding whether you should separately report postoperative wound care during the global period of another procedure, you must first decide whether the reason for the surgery and the reason for the postoperative care are the same.

A sidebar feature in the March 2006 Otolaryngology Coding Alert, -Turn to 24 for Unrelated E/M Services-, generated many reader responses questioning what, exactly, makes a postoperative complication -unrelated- to a previous surgery.

For instance: A Michigan subscriber said, -You should not report modifier 24 [Unrelated evaluation and management service by the same physician during a postoperative period] for postoperative visits for postsurgical infection. You should use modifier 24 only for services that are not related to the surgery- [emphasis in original].
 
The reader goes on to say, -Asking -Would this patient have a postsurgical infection if he had not had the surgery?- should make it very clear that postoperative wound infection is not an unrelated service.-

Ask the right questions: Our experts agree that you should only append modifier 24 to report E/M services unrelated to the previous surgery. But they note that asking -Would this patient have a postsurgical infection if he had not had the surgery?- is not sufficient to make such a determination.

Don't Automatically Link Infections to Surgery

-Although some complications might truly be said to be related to the surgery, like an instrument left in the surgical site or failure to achieve hemostasis before closing, most post-op complications are more closely related to issues such as the patient's general health, compliance with postoperative care instructions, and exposure to infectious organisms,- says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb. -For this reason, I use modifier 24 to describe E/M services for post-op complications in non-Medicare patients.-

She further says that some insurers specifically direct practices to use modifier 24 in this way.

Another factor to consider, Bucknam says, is whether you can be sure that a postoperative infection can really be attributed to surgery. -Patients who are unhealthy, unclean, or who fail to follow medical instructions as to medication, dressing changes, etc., could certainly develop abscesses, ulcerations, hematomas, infections and other common postsurgical complications even without the surgery,- she says. This further validates the decision to treat postsurgical infections as unrelated to the previous surgery.

Different Diagnoses Denote Different Problems

Because the reason for the initial surgery and the reason for postoperative care are different (that is, they require different diagnoses), they qualify as distinct.

-The initial surgery and postoperative infection care would have different diagnosis codes, so that justifies the use of modifier 24 as -unrelated,- - says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery in New York City.

Sandhusen points to the definition of modifier 24 (as outlined in CPT Assistant, August 1998) as further evidence that you should treat postoperative infections as independent of the surgery, at least for payers that follow CPT guidelines: -CPT Assistant says you should use modifier 24 -when a physician provides a surgical service related to one problem and then during the period of follow-up care for the surgery provides an evaluation and management service unrelated to the problem requiring the surgery,- - he says.

-And, note,- Sandhusen adds, -that the phrase stresses that the care is unrelated -to the problem requiring surgery,- not to the surgery itself. Therefore, if the ENT provides wound care for an infection at the site of a previous burn reconstruction, for instance, he is dealing with a different -problem- than the burn, which provided the reason for the initial surgery.-

Medicare applies a different standard: Medicare payers always treat postoperative infections as related to (and therefore, included in the global surgical package of) the initial surgery--unless the ENT must return the patient to the operating room to deal with an infection.

When the ENT must return to the operating room, you may report the appropriate CPT code (for example, 11000, Debridement of extensive eczematous or infected skin; up to 10% of body surface) appended with modifier 78 (Return to the operating room for a related procedure during the postoperative period), for both Medicare and non-Medicare payers, as outlined in -Make Modifier 78 Work for You,- Otolaryngology Coding Alert March 2006, .