Neurosurgery Coding Alert

Patients undergoing complex and delicate neurosurgical procedures are prone to postoperative complications. Such complications may lead to a return to the operating room (OR) for incision and drainage, repair of a cerebrospinal fluid leak, debridement, exploration for infection, a redo laminotomy or other procedure. If a return to the OR is necessary, it will typically occur within the global period of the initial surgery.
 
Note: Part one of this two-part series on postoperative complications will concentrate on cranial procedures. Look to the April 2002 Neurosurgery Coding Alert for a discussion of spinal procedures.
Post-Op Infections
Infection is the most common postoperative complication. This can range from a simple infection at the incision to a serious infection deep within the skull, requiring removal and replacement of a previously placed bone flap.
 
"An infection at the incision is usually resolved medically, with dressing changes and antibiotics," says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. Proper coding for these treatments depends on the payer.
 
"Generally, the surgeon will handle the infection within the global period of the initial procedure," Sandham says. "For payers other than Medicare (i.e., those that follow CPT guidelines), this type of complication is beyond the scope of normal uncomplicated follow-up care." Therefore, it is appropriate to report an E/M service with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) appended. The modifier indicates that the service is not included in the global fee for the initial surgery.
 
For example, a patient undergoes parietal craniotomy for excision of brain tumor (61510, Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma). Several weeks after surgery, signs of infection appear, including redness and pus at the suture line. The surgeon must determine whether antibiotics are warranted, which type, how they should be given and for how long. He or she must also follow the patient closely to ensure proper healing. "These services comprise E/M services not originally compensated in the global care for non-Medicare payers," Sandham says. The services should be reported using the proper level of E/M (e.g., CPT 99213 , Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier -24 appended.
 
For Medicare patients, such postoperative care is included in the global fee for 61510 and cannot be separately billed.
 
For a return to the OR for debridement, the most appropriate codes are 11040-11044, found in the surgery/integumentary system portion of CPT. If, for instance, in the above example the infection had spread beyond the suture to include the surrounding skin and subcutaneous tissue, the [...]