Urology Coding Alert

Tip: Don’t assume post-op care is part of the global surgical package If you’re automatically assuming you can’t separately report a urologist’s treatment of postoperative complications, you could be leaving money on the table. Knowing what qualifies as “typical” care will make your job easier. Determine the Payer First How you deal with postoperative complications depends on the payer you’re dealing with, experts say. Medicare carriers treat postoperative complications differently than insurers who follow CPT guidelines. Although both the Centers for Medicare & Medicaid Services (CMS) and CPT (American Medical Association) guidelines indicate that the global surgical package includes “typical” postsurgical care, the two groups vary on their definition of “typical” --and that means you need to think differently based on the payer.

According to Medicare, all postoperative E/M services, including postoperative care for complications, are included unless they are completely unrelated or meet an exception. (See “These Services Are Not Part of the Global Surgical Package” on the next page for a list of exceptions.)

For procedures, a complication must be significant enough to warrant a return to the operating room or you cannot report a separate procedure. The “Correct Coding” guidelines from CMS 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.

The difference: CPT guidelines are less strict and say that you may report some postoperative E/M services the urologist provides during the global period if they exceed typical follow-up care, even without a return to the OR. Remember Your Modifiers When you report postoperative 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 global period of a surgery.

Modifier 24 is for use of an E/M code during the postoperative period, so you should only append this modifier to E/M codes. To gain reimbursement from private payers for unrelated postoperative evaluations during the global period, you should append modifier 24 to the appropriate E/M service code, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.

Example: If a patient returns to your office with a postoperative infection, such as a patient who has recently undergone an open nephrectomy and returns with signs of infection along the suture line, you may be able to collect an additional $80 from private payers for a level-four established patient visit (99214) for the office visit and urologist’s treatment of the [...]