Practice Management Alert

Question: A patient who is in the 90-day global period of a surgical procedure has complications related to the surgery. Can we bill for the services related to the complications?

Pennsylvania Subscriber

Answer: The answer depends on the payer. Medicare treats payment for post-op complications, such as infections, differently than insurers that follow CPT guidelines.

The difference: Although both CMS (Medicare) and CPT guidelines indicate that the global surgical package includes "typical" postsurgical care, the two disagree on what qualifies as typical --which means you must differentiate your claims depending on the payer you are billing.

Medicare rules: To report a separate code for patients with Part B Medicare for dealing with a complication within a procedure's global period, the circumstances must meet two conditions:

1. Your physician must have treated the patient's complication during a different session from the original procedure.

2. Your physician must have returned the patient to the operating room to treat the complication.If your physician took a Medicare patient to the operating room to deal with a complication during the global period of the original surgery, you'll have to append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to whatever services the physician reports for treating the complication.

CPT rules: The AMA CPT guidelines are less strict and say that you may report some postoperative services your physician provides during the global period if they exceed typical follow-up care, even without a return to the OR.

For E/M services to payers that follow CPT guidelines, you'll need to append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the CPT code to indicate that the service took place during the surgery's global period.