General Surgery Coding Alert

Question: I know to use modifier 78 for a return to the operating room for a post-op infection, but what about the hospital admission service? Can I use modifier 24?

Virginia Subscriber

Answer: When an E/M service occurs during a postoperative global period, but for reasons unrelated to the original procedure, you may append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code, including hospital admission services (99221-99223).

By appending modifier 24 to the E/M code, you make the payer aware that the surgeon is seeing the patient for a new problem, and therefore the E/M service is not included in the previous procedure's global surgical package.

Important: You cannot bill separately for related services during the global period. The global surgical package includes routine postoperative care during the global 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.

Example: A long-term patient has two toes amputated. During postoperative rounds, the surgeon notes an ulcer on the calf region of the same leg, which requires dressing, antibiotics and other attention.

The surgeon performs an evaluation for this new, distinct problem (that is, the ulcer is unrelated to the toe amputation). In this case, you should append modifier 24 to the correct E/M code (for example, 99232, Subsequent hospital care, per day, for the evaluation and management of a patient ...).

Similarly, for payers that follow AMA guidelines, you may report an E/M service separately for care of postoperative infections because the infection itself is distinct from the surgery (see -Infection Isn't Necessarily Related- in General Surgery Coding Alert, Vol. 9 No. 9, page 67).

Critical distinction: CPT and CMS define -related- care differently. In contrast to AMA guidelines, Medicare payers treat 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 (including hospital admissions) 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) to the primary procedure code (for example, 11000, Debridement of extensive eczematous or infected skin; up to 10% of body surface).