General Surgery Coding Alert

Although not uncommon, complications following surgery are an uncommonly troublesome coding challenge. Because CPT and CMS definitions of typical postoperative care differ significantly, whether you should report post-op complications depends on the payer as well as the services or procedures provided.
Whats Typical? It Depends on Whom You Ask  
Under the concept of a global surgical package, carriers bundle or include payment for services integral to a surgical procedure as a part of the procedure and not independently reportable for separate reimbursement, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a physician reimbursement consulting firm in Lakewood, N.J., and vice president of the Coding and Reimbursement Network. For example, compensation for writing orders and conducting hospital rounds during the postoperative period is included in the payment for the surgical procedure, as are other aspects of typical postoperative follow-up care. But CPT and Medicare differ in their definitions of typical postoperative care. What Medicare recognizes as a part of the global surgical package, CPT might define as a separately reportable complication.
 
CPT specifies that follow-up for therapeutic surgical procedures includes only that care which is usually a part of the surgical service. Therefore, you may separately report complications, exacerbations, recurrence or the presence of other diseases or injuries requiring additional services. Similarly, follow-up for diagnostic surgical procedures includes only that care related to recovery from the diagnostic procedure itself, CPT says. Care of the condition for which the diagnostic procedure was performed or of other concomitant conditions is not included and may be listed separately.
 
CMS regulations are stricter and more inclusive than CPT guidelines, and bundle into the global package all additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications. The only exceptions occur when the patient has problems that are unrelated to the surgery, or complications that require a return to the operating room (OR). Medicare also specifically includes the following as part of the global package:
  dressing changes
  local incisional care
  removal of operative packing
  removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts and splints
  insertion, irrigation and removal of urinary catheters, routine peripheral IV lines, nasogastric and rectal tubes
  changes and removal of tracheostomy tubes.
  
 You should further note, The services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, physicians offices. Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon, according to CMS. Under certain circumstances, however, you may report critical care services separately (see Understand Global Periods and Avoid a World of Hurt, General Surgery Coding Alert June 2003, for more [...]