General Surgery Coding Alert

Compare your coding from the quiz on page 25 with our experts' solutions.

Read on to see how your answers stack up -- and how much money your choices cost (or saved) your surgeon.

Solution 1: Partial Mastectomy Following Biopsy

Code the breast biopsy as 19101 (Biopsy of breast; open, incisional). The correct diagnosis code for the findings of infiltrating ductal carcinoma is 174.2 (Malignant neoplasm of upper-inner quadrant of female breast).

For the return to surgery for a partial mastectomy, you should bill 19301 (Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy). The second surgery occurs during the postoperative period of the initial procedure, 19101, which has a 10-day global period. That means you'll need to append modifier 58 (Staged or related procedure or service by the same provider during the postoperative period) to 19301.

Hint: You can find the global days for a surgical procedure by selecting "payment policy indicators" as the type of information when using the Medicare physician fee schedule search at www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx.

Staged: "Because the second procedure during the postoperative period in this scenario is for the same condition that prompted the initial procedure (breast cancer), the partial mastectomy is considered a second 'stage' of the overall treatment for the original condition, even though it wasn't 'planned' in advance," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

According to CMS guidelines, one of the criteria that warrant using modifier 58 is when the subsequent procedure performed during the global period is that the second is "more extensive" than the original procedure for the same condition.

Cost impact: Payment for 19101 is $219.20 (facility national limit amount, conversion factor 34.0376). Reimbursement for 19301 is $640.25 (facility national limit amount, conversion factor 34.0376), which you'd stand to lose if you failed to use modifier 58 indicating that the procedure is not bundled with the global package for the initial 19101 procedure.

Caveat: You'll get full pay when you use modifier 58, but using the modifier starts a new global period. "In other words, you get all of the money for the procedure, but you're also supposed to include all of the postop follow up," Bucknam says.

Bottom line: Bill the case as 19101 and 19301-58 with diagnosis code 174.2.

Solution 2: Breast Biopsy Complication

Report 19101 for the open breast biopsy. The correct diagnosis code for the findings of fibroadenoma is 217 (Benign neoplasm breast).

The infection and abscess at the surgical site is a complication of surgery, and you should report the diagnosis as 998.59 (Other postoperative infection). For the incision and drainage service, report 10180 (Incision and drainage, complex, postoperative wound infection).

Remember modifier: Because the 10180 service occurs during the global period of the 19101 service, you should append modifier 78 (Return to the operating room for a related procedure during the postoperative period) to the 10180 charge.

"You should select modifier 78 in this case, instead of 58, because the second procedure is not a continuation of treatment for the initial condition -- it's not a staged procedure," Bucknam explains. Rather, the second procedure requiring a return to the operating room is treatment for a complication of the initial procedure.

Watch reimbursement: Modifier 78 results in a decrease in reimbursement -- about 15-30 percent for Medicare.

That's because with modifier 78, surgeons are paid only the intraoperative allowance attributed to the fee schedule. Medicare considers that they have already been paid for the preoperative and postoperative portions, given that the global period stays consistent with the original surgery, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Cost impact: Payment for 19101 is $219.20 (facility national limit amount, conversion factor 34.0376). Reimbursement for 10180 is $178.70 (facility national limit amount, conversion factor 34.0376). Of that amount, pre-op and post-op accounts for 0.1 each, while intra-op accounts for 0.8 of reimbursement, according to the fee schedule (columns V, W, and X). In other words, using modifier 78, you can expect payment of $142.96 (0.8 x $178.70) for 10180.

Don't miss: If you mistakenly use modifier 78 when you should have used 58, you stand to unduly cost your practice that 15-30 percent of pay you deserve.

Saving grace: Although modifier 78 reduces your reimbursement, it does not start a new global period. "That means you can make up some of that decreased reimbursement by billing E/M services once the original global period is over," Bucknam says.

Bottom line: Code this case as 19101 with a diagnosis of 217, and 10180-78 with diagnosis code 998.59.