Neurosurgery Coding Alert

Earn an extra $80 or more per claim by knowing when NOT to follow CMS guidelines  If you're including postsurgical infection care in the global surgical package of the primary procedure, you might be missing out on an important source of revenue. To determine if you deserve additional reimbursement, ask yourself these two questions: Question 1: Who's the Payer? Although both CMS (Medicare) and CPT guidelines indicate that the global surgical package includes "typical" postsurgical care, Medicare and private payers differ on what qualifies as typical -- which means you must differentiate your claims depending on the payer you are billing.

"Basically, Medicare requires that a complication must be significant enough to warrant a return to the operating room before you may report a separate procedure," says Susan Allen, CPC, CCS-P, coding manager and compliance officer for Florida Spine Institute in Clearwater, Fla. CMS "Correct Coding" guidelines specifically state, "When the services described by CPT codes as complications of a primary procedure require a return to the operating room" you may report a separate procedure, according to Chapter 1 of the National Correct Coding Initiative (NCCI), version 10.1.

But CPT guidelines are less strict, and you may report some postoperative services during the global period, including treatment of infection, that the surgeon provides in the office. This means, for instance, that you could collect an additional $80 from private payers that follow CMS guidelines for a level-four established-patient visit (99214) to deal with a patient's postoperative infection.

Here's the bottom line: If treatment of a postoperative infection requires a return to the operating room, you may report the procedure for either Medicare or private payers. But if the surgeon can treat the infection in his office, you may only file a separate claim for payers that follow CPT (not CMS) guidelines. Question 2: Which Modifier Do I Need? For both Medicare and private payers, you'll have to append a modifier to the appropriate CPT code to describe the surgeon's treatment of the postsurgical infection.

"If the surgeon is returning to the operating room during the global surgical period of a previous procedure, the correct modifier is -78 (Return to the operating room for a related procedure during the postoperative period)," says Julia A. Appell, CPC, a coder with General & Vascular Surgery PC in South Bend, Ind. And, modifier -78 "indicat[es] that the service to treat the complication required a return to the operating room during the post-operative period," according to CMS guidelines. The use of modifier -78 to indicate a return to the operating room applies to both private and Medicare payers.

For private payers to reimburse for in-office post-operative infection treatment during the global period, you should append modifier -24 (Unrelated evaluation [...]