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Treating Complications for Medicare Patients

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  • July 18, 2014
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Medicare rules for treating complications during the postoperative period differ from CPT® guidelines. Specifically, to separately report treatment of complications to Medicare payers, that treatment must meet one of two conditions:
1. If the provider treats the complication during the initial procedure, the complication must entail treatment demonstrably in excess of that usually required for a procedure of that type. CMS outlines this rule in Chapter I of the National Correct Coding Initiative Policy Manual for Medicare Services:

Treatment of complications of primary surgical procedures is separately reportable with some limitations. The global surgical package for an operative procedure includes all intra-operative services that are normally a usual and necessary part of the procedure…. 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.

This guideline may be difficult to interpret and subject to dispute by providers who disagree about what is “usual and necessary.” To substantiate separate reporting for treatment of complications during the initial procedure, best practice is for the provider to document explicitly the nature of the complication, and the necessity for and effort involved in treatment.
Food for thought: In some cases, the circumstances may better support appending modifier 22 Increased procedural services to the primary procedure code than reporting a separate CPT® code. When appending modifier 22, CPT® guidelines require that provider documentation support “the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of the procedure, severity of patient’s condition, physical and mental effort required.” The provider should explain and identify additional diagnoses, pre-existing conditions, or unexpected findings or complicating factors that contributed to the extra time and effort. For example, use comparisons to clarify how the procedure differed, using quantifiable criteria. For example: “The patient lost 800 cc’s of blood, rather than the usual 100-200 cc’s lost during a procedure of the same type.” Time is also quantifiable (e.g., “the surgery took four hours instead of the usual 1½-2 hours”).
2. If treatment for the complication occurs at a different patient encounter, it must require a return to the operating room. If the provider is able to treat the complication without a return to the operating room, Medicare will bundle the treatment into the initial procedure’s global surgical package. Chapter 12 of the Medicare Claims Processing Manual specifies, “… the global surgical package includes all medical and surgical services required of the surgeon during the postoperative period of the surgery to treat complications that do not require return to the operating room.”
If the provider does return the patient to the operating room to treat a complication during the global period of a previous procedure, you must append modifier 78 Return to the operating/procedure by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period to the code describing the treatment. For example, Chapter I of the Correct Coding Initiative Policy Manual states, “Control of postoperative hemorrhage is … 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.”

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John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering 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.

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