Pulmonology Coding Alert

Learn the differences and save your practice from denials

Coding for post-op infections can get tricky when the infections require readmission to the hospital and additional operating room visits to treat the severity of the infection.

But coding experts have helped us come up with a few scenarios to show you the small differences in coding different levels of infection that will take you a long way to successful reimbursements.

Take a look at the following scenarios to help guide your postsurgical infection billing:

Coding Example A: Several days following a lung transplant (for example, 32851, Lung transplant) a patient develops an infection at the incision site. The patient visits the physician at her office. The physician inspects and cleans the wound, changes the patient's dressings, and administers antibiotics.

Private payer: The physician may report an E/M service (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) appended, depending on the individual carrier's guidelines.

The modifier indicates that the service is not included in the global fee for the initial surgery, explains William J. Conner, MD, physician at Meridian Medical Group, a multispecialty practice in Charlotte, N.C.

Medicare: For a Medicare payer, however, the office visit counts as a part of the global package, and you cannot file an additional claim, Conner says, if the pulmonologist and surgeon report under the same tax identification number.

Coding Example B: Three weeks following surgery, the physician readmits the lung transplant patient to the hospital for a wound abscess but does not return the patient to the operating room.

Private payers: For payers following CPT guidelines, you may report an appropriate admission code (for example, 99221, Initial hospital care, per day, for the evaluation and management of a patient ...) with modifier -24 appended.

Medicare: Once again, you may not report a separate service for Medicare, even though the physician readmitted the patient.

CMS guidelines specify that when the physician readmits the patient within the global period of the original surgery for complications of the original surgery, you cannot charge for the readmission.

Coding Example C: The patient from Example A has a more severe infection, reaching deeper into the surgical wound.

To treat the infection, the physician returns the patient to the OR for debridement (for example, 11000, Debridement of extensive eczematous or infected skin; up to 10% of body surface). In this case, you should report 11000-78 (Return to the operating room for a related procedure during the postoperative period) for both Medicare and private payers.

Don't forget the diagnosis: In all cases, you should link an appropriate diagnosis, such as 998.59 (Other post- operative infection), to any CPT codes you report.

Don't Expect Total Reimbursement With -78

When you're filing claims with modifier -78, don't expect to receive the full fee schedule reimbursement amount, experts say.

Procedures billed with modifier -78 include only the "intraoperative" portion of the service (no payment is made for pre- and postoperative care), says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. Generally, when you bill procedures with -78, you should expect 65-80 percent of the full fee schedule value, depending on the payer. But when you append modifier -78, you do not incur a "new" global period.

Remember: If the pulmonologist and surgeon don't report under the same number, the surgeon's 90-day post-op period does not impact the pulmonologist and the pulmonologist can bill for services without the use of surgical modifiers (as long as the services are medically necessary). 

To avoid denials or complications in your post-op infection cases, always check with your individual carrier's guidelines before you assume you are correct in appending certain modifiers.