Urology Coding Alert

Question: Three weeks after a patient underwent an open nephrectomy, he presented with an infection at the site of the incision. Our urologist took the patient back to the operating room to incise and drain the wound infection. How should I report the second procedure?

Virginia Subscriber
 
Answer: Because the incision and drainage occurred during the global period of the original surgery, you should report the appropriate incision and drainage code, 10180 (Incision and drainage, complex, postoperative wound infection). 
 
Append modifier 78 (Return to the operating room for a related procedure during the postoperative period) since the urologist performed the second procedure to correct a complication arising from or as a result of the first procedure.
 
Coding experts often recommend that you think of modifier 78 as the "complications" modifier. In general, when applying modifier 78 you should meet the following three criteria: 

• The surgeon must undertake the subsequent surgery because of complications from an initial surgery.
• The subsequent surgery occurs during the global period of the initial surgery.
• The subsequent surgery requires a return to the operating room.

CPT differs as to whether some postoperative complications are part of the global surgical package. Most private carriers will reimburse for the treatment of complications in any location using modifier 24 (Unrelated E/M service by the same physician during a postoperative period) on E/M services and modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) on surgical services. Medicare, however, has published clear guidelines stating  that reimbursement for the treatment of postoperative complications will only be made if performed in the operating room.

 -- Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis.