Drain seroma post-op billable?

hsmith67

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Current debate between coders and surgeons: I&D or drain seroma (related to surgery) is separately billable and not "included" in the global period.

Yes/No? Please provide references for use in the debate.

Thanks so much,
Hunter Smith, CPC
 

thomas7331

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Current debate between coders and surgeons: I&D or drain seroma (related to surgery) is separately billable and not "included" in the global period.

Yes/No? Please provide references for use in the debate.

Thanks so much,
Hunter Smith, CPC
Per CMS rules, it's quite clear that it's only billable if it involved a return trip to the OR, otherwise no. What argument is being made that it should be separately billable?

For a reference, see page 6 of the Global Surgery Booklet:

What services are included in the global surgery payment?

Medicare includes the following services in the global surgery payment when provided in addition to the surgery:
...

-All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room.
 
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hsmith67

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Per CMS rules, it's quite clear that it's only billable if it involved a return trip to the OR, otherwise no. What argument is being made that it should be separately billable?

For a reference, see page 6 of the Global Surgery Booklet:

What services are included in the global surgery payment?

Medicare includes the following services in the global surgery payment when provided in addition to the surgery:
...

-All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room.
Thomas - the argument is that it is not on every patient, on rare occasion and global period is to deal with the "common, expected" situations. Therefore it is billable as an unusual/unexpected complication not covered under the global surgical period.

Also, on page 7 of the Global Surgery Booklet it states what is not covered as: Treatment for post-operative complications requiring a return trip to the Operating Room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).

So another part of the argument is that there is a "dedicated procedure room" in the office that a post op patient would be transferred to and the above definition allows for that. It would be nice if the "POS" code/s allowed/not allowed were stated clearly of where an "OR" could or could not be in the booklet.

Thoughts?
 
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Thomas - the argument is that it is not on every patient, on rare occasion and global period is to deal with the "common, expected" situations. Therefore it is billable as an unusual/unexpected complication not covered under the global surgical period.

Also, on page 7 of the Global Surgery Booklet it states what is not covered as: Treatment for post-operative complications requiring a return trip to the Operating Room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).

So another part of the argument is that there is a "dedicated procedure room" in the office that a post op patient would be transferred to and the above definition allows for that. It would be nice if the "POS" code/s allowed/not allowed were stated clearly of where an "OR" could or could not be in the booklet.

Thoughts?
It sounds like this is one of those grey areas that will depend on whether your MAC accepts your practice's definition of a dedicated procedure room. However, based on the examples in the IOM, Medicare wants a room that is devoted to specific procedures, and a room where many types of procedures are performed would be a "minor treatment room."
 

thomas7331

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Thomas - the argument is that it is not on every patient, on rare occasion and global period is to deal with the "common, expected" situations. Therefore it is billable as an unusual/unexpected complication not covered under the global surgical period.

Also, on page 7 of the Global Surgery Booklet it states what is not covered as: Treatment for post-operative complications requiring a return trip to the Operating Room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).

So another part of the argument is that there is a "dedicated procedure room" in the office that a post op patient would be transferred to and the above definition allows for that. It would be nice if the "POS" code/s allowed/not allowed were stated clearly of where an "OR" could or could not be in the booklet.

Thoughts?

Yes, I've seen these arguments and some providers will use these to support billing for services such as this, but I don't think they are persuasive and in my experience payers won't accept them. My on this thoughts are:

With regards to the first argument, that it's a rare or unusual situation - the problem with this is that it's really contrary to the intent of the global period in the first place. The way fee schedules and RVUs are established is that they are not intended to capture reimbursement for only the 'normal' situations. No two procedures are exactly alike, and RVUs are intended to be an average reimbursement that recognizes that some procedures involve more complexity and some less just due to normal variation in patients. The fees that are established already take into account that it's not an exact compensation for any one 'ideal' procedure, but rather a rate that over time should correctly reimburse the providers who perform any given procedure repeatedly. In other words, a provider shouldn't think they're entitled to more for a procedure that was a little more complex or where a patient had a more difficult recovery, any more than they would be expected to accept less reimbursement or offer a the payer a discount on that same procedure if it went smoothly or the patient recovered quickly and required fewer post-op visits.

For the second argument, that an office surgery suite might be considered an 'OR', I agree with the post above that specific payers policies may need to be consulted. But this argument is especially weak with payers because most view an OR as a part of a facility. And as with the argument above, I think it against the intent of the guidelines and it's a real stretch to make a good defense that part of your office is actually an 'OR'. If you are not credentialed as a facility and are billing with an office place of service, then it will be obvious to any payer that this does not meet their definition of a return to the OR so they will either deny the claim with modifier 78 outright, or will very likely pick it up on a post-pay audit since that modifier with the POS 11 or with no facility claim in the patient's history makes it an easy target for an auditor to find potential recoveries.

Hope that helps some.
 

hsmith67

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Yes, I've seen these arguments and some providers will use these to support billing for services such as this, but I don't think they are persuasive and in my experience payers won't accept them. My on this thoughts are:

With regards to the first argument, that it's a rare or unusual situation - the problem with this is that it's really contrary to the intent of the global period in the first place. The way fee schedules and RVUs are established is that they are not intended to capture reimbursement for only the 'normal' situations. No two procedures are exactly alike, and RVUs are intended to be an average reimbursement that recognizes that some procedures involve more complexity and some less just due to normal variation in patients. The fees that are established already take into account that it's not an exact compensation for any one 'ideal' procedure, but rather a rate that over time should correctly reimburse the providers who perform any given procedure repeatedly. In other words, a provider shouldn't think they're entitled to more for a procedure that was a little more complex or where a patient had a more difficult recovery, any more than they would be expected to accept less reimbursement or offer a the payer a discount on that same procedure if it went smoothly or the patient recovered quickly and required fewer post-op visits.

For the second argument, that an office surgery suite might be considered an 'OR', I agree with the post above that specific payers policies may need to be consulted. But this argument is especially weak with payers because most view an OR as a part of a facility. And as with the argument above, I think it against the intent of the guidelines and it's a real stretch to make a good defense that part of your office is actually an 'OR'. If you are not credentialed as a facility and are billing with an office place of service, then it will be obvious to any payer that this does not meet their definition of a return to the OR so they will either deny the claim with modifier 78 outright, or will very likely pick it up on a post-pay audit since that modifier with the POS 11 or with no facility claim in the patient's history makes it an easy target for an auditor to find potential recoveries.

Hope that helps some.
Thanks so much I appreciate all of your feedback and it does support my position.
 

csperoni

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To me, the real key here is whether the carrier follows the CMS definition of global surgical package or the AMA/CPT definition of global surgical package.
The guidance at my employer is to follow CMS guidelines for all carriers. By CMS definition, this is included in the surgical package and not separately billable as it is a complication of surgery. I would not consider a procedure room within your office as an OR.
**IF** the carrier follows the AMA/CPT definition, then I would consider this billable.

Here's a good article regarding the CMS vs AMA/CPT surgical package:
 
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