Primary Care Coding Alert

Question: A patient comes in to the clinic nine days after an I&D performed by his family physician after developing an infection on the site. Patient was given oral antibiotics for the infection. Does this still fall under 10060's 10-day global period or can we code this separately using modifier 24?

Texas Subscriber

Answer: Although this certainly falls within 10060's (Incision and drainage of abscess ...) (I&D) 10-day period for Global Surgical Packages, consideration must be given whether this is a post-op infection directly related to the surgery. To elaborate further, do we really need to consider all postsurgical infections as related to the surgery itself? The answer is no. In a scenario such as above, it would be appropriate to code this separately.

From a physician's point of view, post-op infections do not stem directly from the surgery. Many factors not entirely related to the surgery contribute to the development of infection on a surgical wound. Factors such as age, hygiene, presence of concomitant illnesses, poor wound healing, compliance to antibiotic medications, post-op care, and environment contribute to the development of post-op infections. This should not be considered as related to the surgery. On the other hand, poor surgical technique, surgical tools, and gauzes left in the body are related to the surgery itself.

Considering the above factors, it would be difficult to prove that post-op infections are directly related to the surgery. Therefore, it would be reasonable to code a separate E/M service (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) for this and use a modifier, which in this case is modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period). Moreover, an infection should be reported separately as the medical necessity, since evaluation and management and treatment goals are distinct from the one requiring surgery.

CPT guidance supports this approach. In the Surgery Guidelines, under the heading "Follow-up Care for  Therapeutic Surgical Procedures," CPT states, "Follow-up care for therapeutic surgical procedures includes only that care which is usually a part of the surgical service. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported."

For Medicare beneficiaries, however, any developments within the global period (including infections) apart  from those requiring another surgery are considered part of the surgical package. As a global surgical package component, Medicare includes "Complications Following Surgery -- All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room," according to chapter 12, section 40.1A the Medicare Claims Processing Manual (100-04).