General Surgery Coding Alert

Question: When a patient returns to the operating room for postoperative bleeding on the same date as the original procedure, what modifier would be used on the repair of the bleed? When does the post-op period begin for the first surgery?

Fara Williams
Amarillo Surgical Group, Amarillo, Texas

Answer: As defined by HCFA, the postoperative period begins the day before the surgery was performed and lasts until the end of the specified time period (i.e., 90 days for a 90-day global period), says Kathleen Mueller, RN, CPC, CCS-P, an independent coding and reimbursement specialist in Lenzburg, Ill.

All additional medical or surgical services required by the surgeon due to complications that do not require an additional trip to the operating room (OR) during the postoperative period are included in the global period, says Tammy Chidester, CPC, billing supervisor at Upshur Medical Management Services, a multispecialty coding and billing service in Buckhannon, W.Va.

For treatment of postoperative complications that require a return trip to the OR, modifier -78 (return to the operating room for a related procedure during the postoperative period) should be appended to the code describing the procedure performed on the return trip. The procedure code for the original procedure should not be used unless the identical procedure is performed.

Note: The OR is defined as specifically equipped and staffed for the sole purpose of performing procedures, i.e., a cardiac catheterization suite, a laser suite or an endoscopy suite, but not the patients room, a minor treatment room, a recovery room or intensive care unit, unless the patients condition is so critical that there is not enough time to transport him or her to the OR.