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Urology Coding Alert

Code Post-Op Complications Based on Payer and Site of Service

Published on Sat Sep 01, 2001

Receiving reimbursement for treating postoperative complications within the global period of the initial surgical procedure requires coders to bill according to two factors: the site of service (operating room or outpatient) and the payer (Medicare or commercial).
 
Medicare will pay for treatment of postoperative complications as long as the patient returns to the operating room (OR) for treatment. However, Medicare does not cover the treatment of post-op problems in the office, emergency department or hospital treatment room ("day surgery").
 
Commercial payers that follow CPT rules do not usually reimburse for treatment of complications within the global period no matter where they are treated. However, commercial payers who view a complication as a new problem will pay for it, says Michael A. Ferragamo, MD, assistant clinical professor of urology at the State University of New York, Stonybrook.

Use Modifier -24 or -78
 
Whether to append modifier -24 or -78 depends on the site of service.
 
  • Modifier -24: When treating a commercial insurance patient in the office for a complication, bill for an office visit (99212-99215) with modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period), indicating that the complication is a "new problem" as viewed by the commercial payer. Medicare will not cover a post-op complication  office visit.
     
  • Modifier -78: When taking a Medicare or commercial patient back to the OR for treatment of a postoperative complication, append modifier -78 (return to the operating room for a related procedure during the postoperative period) to the code for the procedure being performed, and you will receive the intraoperative fee, about 75 to 80 percent of the global fee.

    • Common Postoperative Complications
     
    1. TURP:     The most notorious example of the difference between Medicare and CPT postoperative rules is coding for control of bleeding after a transurethral electrosurgical resection of prostate (TURP, 52601, transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]). While the CPT descriptor clearly states that control of postoperative bleeding is included in the global package, Medicare will pay separately for post-op control of bleeding if performed in the OR. This should be coded 52214 (cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands) with modifier -78 appended.
     
    If the Medicare patient has a TURP, and a week later is treated for bleeding in the office by inserting a catheter and irrigating, it is not separately billable, Ferragamo says.
     
    If a patient with commercial insurance has a TURP and has postoperative bleeding, the commercial payer will not reimburse for either irrigation in the office or fulguration in the OR because the commercial payer is following CPT rules, and the CPT descriptor for the TURP includes control of postoperative bleeding.
     
    But if the commercial TURP patient has a postoperative complication other than bleeding, the office visit is separately billable. For example, the patient has a TURP and the next week presents with acute epididymitis, 604.90. The payer views this as a new problem even though it is also a complication of the surgery. The carrier will reimburse for the office visit with modifier -24 appended. Also bill 54700 (incision and drainage of epididymis, testis and/or scrotal space [e.g., abscess or hematoma]) for treating the scrotal abscess with modifier -79 appended.
     
    Note: As with any procedure and E/M on the same day, append modifier -79 (unrelated procedure or service by the same physician during the postoperative period) to the procedure and modifiers -24 and -25 to the E/M service if the payer is commercial.
     
    "With Medicare, make sure the patient's problem is unrelated to the initial surgery if you are billing with modifiers -24 or -79," says Nelda Laskey, RHIT, coding supervisor with Garden City Medical Clinic in Garden City, Kan. "For example, a ureteral stone would be unrelated to the TURP." Coders should check with the physician if the documentation doesn't clearly indicate whether the new diagnosis is related.
     
    2. Radical prostatectomy: A radical prostatectomy (55810-55815, 55840-55845) presents similar coding problems as a TURP. For example, a postradical prostatectomy patient develops a bladder neck contracture with obstructive urinary symptoms within the postoperative period. The urologist dilates the bladder neck stricture, commonly referred to as an anastomotic stricture, in the office.
     
    "That's a complication of the surgery, and Medicare won't pay if you do the dilation in the office instead of in the OR," Ferragamo says. "But a commercial company will pay for the visit because they view it as a new problem." Append modifiers -24 and -25 to the office visit and modifier -79 to the bladder neck dilation: 53600 (dilation of urethral stricture by passage of sound or urethral dilator, male; initial) or 53620* (dilation of urethral stricture by passage of filiform and follower, male; initial).

    Check With Your Payer
     
    Because commercial payers have differing (and usually unpublished) rules about treatment of postoperative complications, ask your payer how to file first. "They may not know the answer when you call," Ferragamo says. "Some coders just file first and see how the carrier handles the claim. Then they know what to do in the future." Either way, be prepared to wait for a clear-cut answer.

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