Neurosurgery Coding Alert

Question: Three weeks after a patient underwent an anterior cervical diskectomy and fusion, he presented with an infection at the site of the incision. Our neuro-surgeon took the patient back to the operating room to debride the wound. How should I report the second procedure?


Virginia Subscriber

Answer: Because the debridement procedure occurred during the global period of the original surgery, you should report the appropriate incision and drainage code, such as 10180 (Incision and drainage, complex, postoperative wound infection). Append modifier 78 (Return to the operating room for a related procedure during the postoperative period) because the second procedure occurred due to complications from the first procedure.

Coding experts often recommend that you think of modifier 78 as the -complications- modifier. You should apply modifier 78 when you meet three criteria:

- The surgeon must undertake the subsequent surgery because of complications from an initial surgery.
- The subsequent surgery occurs during the global period of the initial surgery.
- The subsequent surgery requires a return to the operating room.

While CPT differs as to whether some postoperative complications are part of the global surgical package, Medicare has published clear guidelines, and most payers have adopted them as their own standard.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.