General Surgery Coding Alert

Question: Nine days after a laparoscopic cholecystectomy (90-day global), a third-party insured patient was admitted for bile leak and developed peritonitis. May I charge for a consult for the follow-up and, if so, are any modifiers necessary?


Wisconsin Subscriber

Answer: The correct answer depends on whether your payer follows CPT (AMA) or CMS (Medicare) guidelines regarding postoperative complications.

For payers following CPT guidelines, you must show that the E/M service (in this case, presumably an inpatient consultation, 99251-99255) that occurs during a previous procedure's global period is -unrelated- to the primary procedure (here, for instance, 47562, Laparoscopy, surgical; cholecystectomy). Under a widely accepted coding rule (accepted by the AMA and all insurers), related care during the postoperative period is bundled to, or included in, payment for the primary procedure.

The crucial question then becomes, is the postoperative infection -related- to or -unrelated- to the primary surgical procedure?

In fact, although some complications might truly 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.

Further, 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.

Therefore, you should be able to report the consult for infection during the cholecystectomy's global period, but you will have to append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).

The AMA-s CPT Assistant (August 1998) has clarified that 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.- This definition stresses that the care is unrelated -to the problem requiring surgery,- and not to the surgery itself. Be sure to link the peritonitis diagnosis to the consult.

Medicare and payers that follow CMS guidelines play by a different set of rules. In a nutshell, and in contrast to the AMA, CMS treats all infections during the postoperative period as related to the primary procedure and will not pay separately for this type of care.

Therefore, for Medicare or any other payer following CMS rules, you can't report a separate E/M service (whether consultation or otherwise and regardless of any modifiers you might append) for care of a postoperative infection during the global period.

Only if the infection is bad enough to prompt a return to the operating room can the physician charge separately for his work, and then only if you append modifier 78 (Return to the operating room for a related procedure during the postoperative period).

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, manager of compliance education at the University of Washington Physicians.