General Surgery Coding Alert

When deciding whether you should separately report postoperative wound care during the global period of another procedure, you must first decide if the reason for the surgery and the reason for the postoperative care are the same.

Our May 2004 cover story, "2 Questions to Ask Yourself When Reporting Postoperative Infections," generated many reader responses questioning what, exactly, makes a postoperative complication "unrelated" to a previous surgery.

For instance, a Wisconsin subscriber suggested, "You should not report modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) for postoperative visits for post-surgical infection. You should use modifier -24 only for services that are not related to the surgery."

The reader goes on to say, "Asking, 'Would this patient have a postsurgical infection if he had not had the surgery?'should make it very clear that postoperative wound infection is not an unrelated service."

Our experts agree that you should only append modifier -24 to report E/M services unrelated to the previous surgery. But they note that asking, "Would this patient have a post-surgical infection if he had not had the surgery?" is not sufficient to make such a determination.

"Although some complications might truly be said to be related to the surgery, like an instrument left in the surgical site or failure to achieve hemostasis before closing, most post-op complications are more closely related to issues such as the patient's general health, compliance with postoperative care instructions, and exposure to infectious organisms," says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb. "For this reason, I use modifier -24 to describe E/M services for post-op complications in non-Medicare patients." She further notes that some insurers specifically direct practices to use modifier -24 in this way.

Another factor to consider, Bucknam says, is whether you can be sure that a postoperative infection can really be attributed to surgery. "Patients who are unhealthy, unclean, or who fail to follow medical instructions as to medication, dressing changes, etc., could certainly develop abscesses, ulcerations, hematomas, infections and other common post-surgical complications even without the surgery," she says. This further validates the decision to treat postsurgical infections as unrelated to the previous surgery.

Because the reason for the initial surgery and the reason for postoperative care are different (that is, they require different diagnoses), they qualify as distinct from one another.

"The initial surgery and postoperative infection care would have different diagnosis codes, so that justifies the use of the -24 modifier as 'unrelated,'" says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.

Sandham also points to the definition of modifier -24 (as outlined in CPT Assistant, August 1998) as further evidence that you should treat postoperative infections as independent of the surgery itself, at least for payers that follow CPT guidelines. "CPT Assistant says you should use modifier -24, 'when a physician provides a surgical service related to one problem and then during the period of follow-up care for the surgery provides an evaluation and management service unrelated to the problem requiring the surgery.'"

"Note," Sandham continues, "that the phrase stresses that the care is unrelated 'to the problem requiring surgery,' not to the surgery itself. Therefore, if the surgeon provides wound care for an infection at the site of a previous hernia repair, for instance, he is dealing with a different 'problem'than the hernia, which provided the reason for the initial surgery."

Remember: Medicare applies a different standard. Medicare payers always treat postoperative infections as related to (and therefore, included in the global surgical package of) the initial surgery unless the surgeon must return the patient to the operating room to deal with the infection.

In cases when the surgeon must return to the operating room, you may report the appropriate CPT code (for example, 11000, Debridement of extensive eczematous or infected skin; up to 10% of body surface) with modifier -78 (Return to the operating room for a related procedure during the postoperative period) appended.