Urology Coding Alert

Tip: Don’t assume post-op care is part of the global surgical package

If you’re automatically assuming you can’t separately report a urologist’s treatment of postoperative complications, you could be leaving money on the table. Knowing what qualifies as “typical” care will make your job easier.

Determine the Payer First

How you deal with postoperative complications depends on the payer you’re dealing with, experts say. Medicare carriers treat postoperative complications differently than insurers who follow CPT guidelines. Although both the Centers for Medicare & Medicaid Services (CMS) and CPT (American Medical Association) guidelines indicate that the global surgical package includes “typical” postsurgical care, the two groups vary on their definition of “typical” --and that means you need to think differently based on the payer.

According to Medicare, all postoperative E/M services, including postoperative care for complications, are included unless they are completely unrelated or meet an exception. (See “These Services Are Not Part of the Global Surgical Package” on the next page for a list of exceptions.)

For procedures, a complication must be significant enough to warrant a return to the operating room or you cannot report a separate procedure. The “Correct Coding” guidelines from CMS specifically state, “When the services described by CPT Codes as complications of a primary procedure require a return to the operating room” you may report a separate procedure.

The difference: CPT guidelines are less strict and say that you may report some postoperative E/M services the urologist provides during the global period if they exceed typical follow-up care, even without a return to the OR.

Remember Your Modifiers

When you report postoperative services to payers that follow CPT guidelines, you’ll need to append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the CPT code to indicate that the service took place during the global period of a surgery.

Modifier 24 is for use of an E/M code during the postoperative period, so you should only append this modifier to E/M codes. To gain reimbursement from private payers for unrelated postoperative evaluations during the global period, you should append modifier 24 to the appropriate E/M service code, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.

Example: If a patient returns to your office with a postoperative infection, such as a patient who has recently undergone an open nephrectomy and returns with signs of infection along the suture line, you may be able to collect an additional $80 from private payers for a level-four established patient visit (99214) for the office visit and urologist’s treatment of the infection.

CMS and CPT agree: If the physician must return to the OR to deal with post-op complications, both Medicare and private payers will pay at a reduced rate when you append the appropriate modifier to the CPT code to describe the urologist’s treatment of the postsurgical complication. If the physician is returning to the operating room for a related procedure to care for a complication during the global period of a previous surgery, the correct modifier is 78 (Return to the operating room for a related procedure during the postoperative period).

But you will be paid at the full rate for unrelated procedures (unrelated to the previous surgery, not a complication) when you use modifier 79 (Unrelated procedure or service by the same physician during the postoperative period).

Example: A patient undergoes a transurethral resection of an enlarged prostate gland (TURP). Four days after the surgery, the patient has heavy bleeding and hematuria and is returned to the OR for surgery to control the bleeding. This represents a complication that required a return to the OR for treatment within the global period of the initial procedure, so you should report 52214-78 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands).

Append modifier 78 to 52214 to indicate that your physician performed surgery in the OR to correct complications after a prior procedure.

CMS and CPT differ in their definitions of “related.” CMS generally considers any subsequent procedures that occur in the same area to be related, even if done for a different diagnosis, or for post-op complications, says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.

“CPT, while less clear about the use of the terms, seems to allow treatment of different conditions to be considered ‘unrelated’ when they represent the onset of a new problem requiring a new evaluation (such as post-op infection).” A “related” procedure would be one that is an extension of the original surgery (e.g., revising the location of an intrathecal catheter), Sandhusen says.
  
Best practice: If your urologist returns the patient to the OR for postoperative complications such as treatment of a postoperative infection, report the procedure for Medicare with modifier 78 and consider whether it may warrant modifier 79 for non-Medicare payers that adhere to CPT. If the urologist treats the infection in his office, however, you may only file a claim for those payers that follow CPT guidelines by using modifier 24 with the E/M service.