Urology Coding Alert

Question: What modifier should we use on an evaluation and management (E/M) service for a medical complication after surgery in the surgical global for the private sector? I know Medicare will not pay for this service.

New York Subscriber

Answer: The cautionary view would say that there are no CPT modifiers that allow the reporting of an E/M service for a complication treated during the global period of a surgical procedure. However, for those payers using St. Anthony/McGraw-Hill Relative Values for Physicians (RVP), modifier -78 (return to the operating room for a related procedure during the postoperative period) may be recognized and paid when attached to the CPT code for a related procedure performed in the physicians office or other outpatient setting during the postoperative period.

But there is an argument to be made here. CPT 2000 states that the surgical package is related strictly to the procedure and the normal postoperative course. This would mean that postoperative complications are not included. So it would be appropriate to charge an E/M service when you see a complication.

You need to use modifier -24 (unrelated E/M service by the same physician during a postoperative period). As an example, consider a patient who had a pulmonary embolism from a venous thrombosis in the postoperative period for a radical prostate procedure. The physician could charge for this E/M service using modifier -24. Of course, this applies to private payers only. As the subscriber notes, Medicare will not pay for an E/M service during the postoperative period.