Part B Insider (Multispecialty) Coding Alert

Remember: Medicare only pays for surgical complications during the global if they require a return to the OR.

Many aspects of global surgery billing can trip up even the most experienced coder --but its the use of modifier 79 that has the OIGs radar beeping.

Last month, the OIG issued a management implication report on the misuse of modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) in change request 6334 (www.cms.hhs.gov/transmittals/downloads/R442OTN.pdf).

What happened was, the OIG got wind of some abusive practices happening with this modifier, and the investigation substantiated that a provider was appending modifier 79 to all of his surgical claims between 1994 and 2000, said Donna Pisani, provider outreach and education consultant with National Government Services (NGS), during an April 22 global surgery conference call. NGS is a Medicare payer in 25 states.

Now the OIG has asked all contractors to look at the codes with modifier 79 appended, so be aware if youre using modifier 79 that youre using it appropriately and your records reflect the documentation, Pisani noted.

Global period: Pisani reinforced the concept of the global surgical billing during the call. The global package includes the preoperative visit the day before the surgery, intraoperative services, postsurgical complications, postoperative visits during the global period, post-surgical pain management services by the surgeon, and miscellaneous services such as dressing changes, suture removal, staples, etc., she noted.

Modifiers: In some circumstances, youll find the need to perform a separate procedure during a surgerys global period, requiring you to append a modifier to the code. Youll call on modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) when a secondary surgery is performed during the postop period of another surgery and the subsequent procedure was planned or staged, Pisani noted.

Modifier 78 (Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postop period) applies to the service when the physician has to return the patient to the operating room for a related procedure during the postoperative period, Pisani said.

Keep in mind: Medicare will only pay for surgical complications during the global period if they require a return to the operating room. This differs from CPT coding rules -- the AMA advises that related complications may be reimbursable even if the patient does not return to the OR. Medicare, however, will not pay for those situations.

If your patient has a complication unrelated to the original surgery, you can usually bill for the service, even if the patient is not returned to the operating room. In that case, youd append modifier 79 if the physician performs a procedure or surgery; or you can append modifier 24 (Unrelated E/M service by the same physician during a postoperative period) if the physician performs an E/M service for the unrelated procedure during the global period.

Split care: You may come across a situation when one physician performs the surgical care and another performs the pre- or postoperative care.

When two or more physicians perform services included in the global fee, the sum of the amount approved for all providers cannot exceed that which would have been paid if a single doctor performed all of the services, noted DeEtte Minerley, provider outreach and education consultants with NGS, during the call.

Important: Both the bill for the surgical care only (which will have modifier 54 appended) and the bill for the postop care only (which will include modifier 55) must contain the same date of service (the surgical date) and the same procedure code,Minerley noted. The date that care was assumed must also go on the claim -- youll put that date in item 19 or in the narrative field if you file electronically, she added.