Otolaryngology Coding Alert

If you're treating Medicare and private-payer claims the same, you could forfeit $80 or more per claim If you include postsurgical infection care in your primary procedure's global surgical package every time, stop. You could be missing out on legitimate revenue. To determine whether you deserve additional reimbursement, ask yourself two questions: Question 1: Who's the Payer? Medicare treats postoperative complications, including infections, differently than insurers who follow CPT guidelines. Although both CMS (Medicare) and CPT guidelines indicate that the global surgical package includes "typical" postsurgical care, the two sources differ regarding what qualifies as typical -- which means you must differentiate your claims depending on which payer you bill. Generally, Medicare requires that a complication be significant enough to warrant a return to the operating room before you may report a separate procedure. In fact, 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. But CPT guidelines are vague, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Some payers may allow you to report some postoperative services that CMS typically bundles into the global period, including infection treatment that the surgeon provides in the office, she adds. This means, for instance, that you may be able to collect payment from private payers for a level-three or -four established patient visit (99213 or 99214) to deal with a patient's postoperative infection depending on the documentation. The bottom line: If treatment of a postoperative infection requires the otolaryn-gologist to return the patient to the operating room, you should report the procedure to either Medicare or private payers. If the surgeon can treat the infection in his office, however, you may be able to file a claim only to those payers that do not follow CMS guidelines, Pohlig says. "You should query the payers in writing beforehand to ensure proper coding and billing compliance," she says. Private payers do not have clear-cut rules, Pohlig notes. In fact, many of their coding guidelines are contractual. "What may be negotiated for one physician group may not be included in another group's contract," she says. Question 2: Which Modifier Should I Use? For both Medicare and private payers that recognize them, you'll have to add a modifier to the appropriate CPT code to describe the otolaryngologist's postsurgical infection treatment. "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 Sharon Tucker, CPC, [...]