You Break It, You Buy It: Fact or Fiction?

Question: I have a provider who insists that the “you break it, you buy it” rule is a coding urban legend. Is this guideline supported by policy?

Answer: The “you break it, you buy it” rule states that a surgeon cannot separately report (and receive compensation for treating) a complication during surgery if the complication occurs as a result of the surgery itself. This is demonstrated in the following example: If a surgeon injects epinephrine to control bleeding during a polyp removal (e.g., 45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique), control of bleeding is not separately reported because the hemorrhage is due to snare polypectomy.

The basis of the “you break it, you buy it” rule is found in the National Correct Coding Initiative Policy Manual for Medicare Services. Chapter 1.C.13 allows, “Treatment of complications of primary surgical procedures is separately reportable with some limitations” [emphasis added]. Those limitations, however, are considerable. Specifically:

 … treatment of a complication of a primary surgical procedure is not separately reportable (1) if it represents usual and necessary care in the operating room during the procedure or (2) if it occurs postoperatively and does not require return to the operating room.

For example, control of hemorrhage is a usual and necessary component of a surgical procedure in the operating room and is not separately reportable. Control of postoperative hemorrhage is also not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable with modifier 78 [Unplanned Return to the Operating/Procedure Room By the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period].

Additional restrictions are found throughout the NCCI Policy Manual. For example, chapter 1.R states, “Complications inherent in an invasive procedure occurring during the procedure are not separately reportable. For example, control of bleeding during an invasive procedure is considered part of the procedure and is not separately reportable.”

Chapter 5.E.3 further advises:

If an iatrogenic laceration of the spleen occurs during the course of another procedure, repair of the laceration with or without splenectomy is not separately reportable. Treatment of an iatrogenic complication of surgery such as a splenic laceration is not a separately reportable service. For example if an iatrogenic laceration of the spleen occurs during an enterectomy, colectomy, gastrectomy, pancreatectomy, or nephrectomy procedure, the physician should not separately report a splenectomy CPT code (e.g., 38100, 38101, 38120).

Finally, chapter 6.E.9 states:

If an iatrogenic laceration/perforation of the small or large intestine occurs during the course of another procedure, repair of the laceration/perforation is not separately reportable. Treatment of an iatrogenic complication of surgery such as an intestinal laceration/perforation is not a separately reportable service. For example CPT codes describing suture of the small intestine (CPT codes 44602, 44603) or suture of large intestine (CPT codes 44604, 44605) should not be reported for repair of an intestinal laceration/perforation during an enterectomy, colectomy, gastrectromy, pancreatectomy, hysterectomy, or oophorectomy procedure.

In a nutshell: If the complication arises from the surgery, and the primary surgeon is able to deal with it at the time of the initial surgery, policy allows very little room to report treatment for the complication. As stated above in chapter 1.C.13, however, you may report treatment that requires a return to the operating room. This is further confirmed in chapter 5.C.5, which states, “If bleeding occurs in the postoperative period and requires return to the operating room for treatment, a HCPCS/CPT code for control of the bleeding may be reported with modifier 78 indicating that the procedure was a complication of a prior procedure requiring treatment in the operating room.”

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 404 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

3 Responses to “You Break It, You Buy It: Fact or Fiction?”

  1. Rebecca Johnson says:

    So, after surgery….if they have problems, for example; Wound dehiscense or surgical wound not healing….is that included in the surgical package also?

  2. Aubrey says:

    What about a diabetic patient who receives a c/s and has a non-healing wound from the c/s incision due to her underlying diabetes and has to be seen every day for three weeks straight post-operatively?

  3. Deborah Harlow says:

    Rebecca,
    If the post-operative wound complications require a return to the OR for treatment such as an I & D, that is separately billable, using modifier 78. Otherwise, it is part of the global package.

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