Neurosurgery Coding Alert

When deciding whether you should separately report postoperative wound care during the global period of another procedure, you must determine if the reason for the surgery and the reason for the postoperative care are the same. Our June 2004 cover story, "2 Questions Help You Report Postoperative Infections for the Best Results," 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. Don't Automatically Link Infections to Surgery "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 (for instance, Blue Cross/Blue Shield) 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. Different Diagnoses Denote Different Problems 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.

"On a very basic level, the initial surgery and the postoperative infection care would have different diagnosis codes, so that supports the use of the -24 modifier as 'unrelated,'" says Eric Sandham, CHC, CPC, compliance manager for Central [...]