Wiki Billing critical care after cardiac surgery

[lydiachitwood]

Hello,
Has anyone come across a scenario where the patient has cardiac surgery and a third chest tube is placed in the pleural space. The days that the patient remains in the hospital is it appropriate to code critical care because the patient develops pleural effusion?

Also, would it be appropriate to bill a discharge when the patient goes home, with a modifier 24 due to the pleural effusion?

My understanding has always been that pleural effusion is a complication of the open heart surgery and therefore, thoracentesis done by the bedside is not billed separately.

Of course, if the patient needs to be returned to the operatiing room then we would bill with either 78 or 79 modifier.

But overall, is pleural effusion separate and distinct after cardiac surgery and should the dr's involvement in seeing the patient afterwards for this warrant coding critical care?

 

[ABridges]

If a thoracentesis is performed after surgery it should be billed. The global period is contained to the main cardiac codes and anything that is done after the primary procedure that is not directly related to the heart can and should be billed separately.

There is no global period for a chest tube (32551), therefore anything that is related to the pleural effusion should be billed.

 

[AB87]

Yes i agree. I do Open Heart Also, and a Effusion is a "Separate Condition" from the Surgery. So you want to make Sure you Capture all those Charges.

 

[lydiachitwood]

Help!

yet, in a STS newsletter dated 2004 (and is still accurate info per Julie Painter 9/2012)
"post-operative services included in the cardiothoracic surgical package" include "pleural effusion/thoracentesis" with the statement that this service is billable only "if the treatment requires a return to the OR, or a special procedures room, modifier 78 should be appended to the correct CPT procedure code".

So what this tells me is:

1. Pleural effusion does not indicate a separate condition unrelated to the surgery.

2. If the patient must be tapped, the procedure must take place in a procedure room, not at the bedside or ER.

3. If the thoracentesis is billable, modifier 78 should be appended which indicates that it was related to the original surgery.

Am I losing it?????

 

[emoates]

yet, in a STS newsletter dated 2004 (and is still accurate info per Julie Painter 9/2012)
"post-operative services included in the cardiothoracic surgical package" include "pleural effusion/thoracentesis" with the statement that this service is billable only "if the treatment requires a return to the OR, or a special procedures room, modifier 78 should be appended to the correct CPT procedure code".

So what this tells me is:

1. Pleural effusion does not indicate a separate condition unrelated to the surgery.

2. If the patient must be tapped, the procedure must take place in a procedure room, not at the bedside or ER.

3. If the thoracentesis is billable, modifier 78 should be appended which indicates that it was related to the original surgery.

Am I losing it?????

It was always my understanding that it was part of the global package unless you could prove that the effusion was not a result of the surgery performed.

Erin

 

[lydiachitwood]

thank you.

 

[ABridges]

I actually disagree.

Pleural Effusion is not what the patient had open heart surgery for; the surgery was due to cardiac disease. Not every patient develops pleural effusion during the recovery period because it is not part of the "normal" recovery process. Any procedures that are performed due to PE can and should be billed in addition to the main surgical codes.

 

[emoates]

Pleural Effusion after cardiac surgery

UpToDate
“Postoperative pleural effusions are common in patients who undergo cardiac surgery [1-13]. Most of these effusions develop as a consequence of the surgical procedure itself ("nonspecific pleural effusions") and follow a generally benign course. Postoperative pleural effusions may also occur with postpericardiotomy syndrome (PPCS, also known as the postcardiac injury syndrome or Dressler's syndrome), or as the initial manifestation of a potentially serious complicating event, such as heart failure or pulmonary embolism (table 1).
The extent of the evaluation required for a postoperative pleural effusion depends upon the presence of associated cardiovascular symptoms and the volume, timing of onset, progression, and persistence of the pleural effusion. Effusions with the following characteristics almost invariably represent nonspecific pleural effusions, and require only observation:
 Small to moderate in size
 Present within one to two days after surgery and not progressive
 Not associated with respiratory symptoms
On the other hand, symptomatic, large, or progressive pleural effusions require thoracentesis with pleural fluid analysis, and, in some instances, further evaluation with serum brain natriuretic peptide (BNP), echocardiography, helical chest CT, or other diagnostic studies. Postoperative pleural effusions can also be caused by hemothorax, pneumonia, pleural infections, central venous catheter erosion, mediastinitis, or chylothorax [14-16]. (See "Diagnostic evaluation of a pleural effusion in adults: Initial testing".)"

American College of Chest Physicians
"Coronary artery bypass graft (CABG) surgery is performed on more than 600,000 patients per year in the United States.1 Patients commonly develop pleural effusions directly related to this surgery, making this procedure one of the most common causes of a pleural effusion. The cause and management differs because of the varied pathogenesis and time course of these pleural effusions. These effusions can be most appropriately categorized by time intervals: (1) perioperative (within the first week); (2) early (within the first month); (3) late (2 to 12 months); and (4) persistent (after 6 months).
Although the pathophysiology of pleural effusions in the perioperative period following CABG can differ, these effusions usually will resolve without intervention. The effusions that occur later than 1 week and within 1 month typically are associated with acute chest pain and fever and usually require antiinflammatory medication. The persistent effusions are the consequence of dysfunctional healing of the pleural space resulting in a visceral pleural peel or fibrosis, which may lead to a trapped lung that may require decortication."

Abstract from The Annals of Thoracic Surgery
"Pleural effusion is a common occurrence following heart surgery, but in most cases the fluid collection is small and not clinically significant. Some patients, however, develop a significant effusion during the initial hospitalization or after hospital discharge, which requires drainage to relieve respiratory symptoms."

 

[lydiachitwood]

So from a clinical standpoint, pleural effusion can be a complication of the cardiac surgery, unless it is documented that the patient had a prior existing condition for which I could then bill with modifier 24 or 79 if appropriate.

From a coding standpoint, who has the final word? The STS says PE is a complication. Does CMS comment on this? Otherwise, I feel the STS is correct.