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 [...]
