I showed them this part of the CMS article, and tried explaining it is global, but the doctor still disagreed. The doctor performs office procedures in the office, removal of lesions etc that do not warrant the hospital OR, so he is telling me it is ok, he is doing it in an operating room, to use modifier 78. (The changes in the wording of modifier 78 this year, leans the doctor to this modifier.
A. Components of a Global Surgical Package
"Complications Following Surgery - All additional medical or surgical services
required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room;"
But then there is this following statement, in the manual, and according to the doctor and his wife, the hematoma is not part of normal recovery from surgery. I somewhat agree, but to me when there are abdominplasty, or surgeries of that extent etc done, a hematoma (maybe not part of normal recovery) could be expected to happen, and I do not see the medical necessity in billing for it. Plus, then I would have to use modifier ?, modifier 79would not be correct, it is not unrelated (without the procedure being done the patient would not have had the hematoma); could you use modifier 58, I know it is not stage, but in the reading of the description it states "or related procedure"
B. Services Not Included in the Global Surgical Package
"Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;"
the quotes are from Chapter 12 of CMS Medicare claims processing Manual.
confused, I had this straight, but know with the doctors view, I am needing other coders opinions. and opinions how to address this to the doctor and his wife. The insurance person before me was adding modifier 24 to the px

The doctors wife's opinion is if we have to go back to the hospital OR we will.

again I am scared the doctor would be faced with medical necessity.
Sorry for such a long reply, I think I may be putting too much into this.
codegirl0422, CPC, CBCS
It's included per CMS's guidelines... but not included per CPT guidelines... so both your docs are right in a way... it depends on what kind of insurance the patient has.
For Medicare and any payor who follows CMS guidelines, treatment of post-op complications are included unless the patient is returned to the operating room.
It's a good idea to have the Guidelines handy so you can defend yourself.. you know what you are talking about!
Also, it's a good idea to check all of your payors' surgical package guidelines. Most of them are published on their website.... and most ARE following CMS guidelines.

Erica