Published 11/1/2011
Margaret M. Maley, BSN, MS

When it’s not your complication

How to report services provided to your partner’s patient during the postoperative period

If a complication arises after surgery, prompt treatment is required. But if your partner, the orthopaedist who performed the surgery, is unavailable and you step in to provide the care, how should you report and code the service? To better appreciate how these services should be reported, you must first understand what is included in the global surgical package related to postoperative care.

According to Current Procedural Terminology (CPT), “typical” follow-up care is included in the surgical service. CPT does not mention a specific number of days that are included or anything about treating complications. Payers generally have a more specific definition of what is included in the global reporting of a surgical service.

Under Medicare, the surgical package for a major procedure includes 90 days of follow-up care. This care includes the treatment of complications, unless the complication returns the patient to the operating room for treatment. Medicare very narrowly defines an operating/treatment room as follows:

“A place specifically equipped and staffed for the sole purpose of performing procedures. The term operating room includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient 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 operating room).”

The following example shows how these rules and this definition apply when treating a partner’s patient for a postoperative complication.

Within the global period
Your partner performed an anterior cruciate ligament (ACL) reconstruction on a 22-year-old male. Six weeks after surgery, the patient makes an appointment with you because his knee is swollen and your partner is out of town. You examine the patient in your office, order and evaluate radiographs, aspirate the knee, and scheduled him for surgery the following morning to clean the knee out arthroscopically. How do you report these services?

You must report the services exactly as your partner would if he or she saw the patient personally. If the payer follows Medicare reimbursement rules, you would report as follows:

  • The evaluation and management (E&M) service and aspiration would not be reportable because they were performed in the office, not in the operating room.
  • The radiographs you ordered and evaluated would be separately reportable because they are not included in the global period of the surgery.
  • The arthroscopy performed the following day to clean out the knee would be reportable with modifier 78 appended, indicating a return to the operating room for an unplanned, related procedure.

If the payer follows CPT rules and has a 90-day global period, the E&M service would not be reportable because seeing the patient in the postoperative period is considered typical follow-up care. The joint aspiration, however, may be reportable and would be submitted without a modifier. Neither modifier 79 (indicating that the aspiration was unrelated to the surgery) nor modifier 78 (which requires a return to the operating room) can be used in this situation.

The arthroscopy would be reported exactly as stated above for Medicare, with modifier 78 appended. In 2008, the words “procedure room” were added to the definition of modifier 78, so that the current CPT definition of modifier 78 is as follows: “An unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period. It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure.”

When modifier 78 is appended to a surgical code, the reimbursement is reduced by approximately 30 percent, and the global period of 90 days is counted from the original surgery, not the date the complication was treated in the operating/procedure room.

Outside the global period
Using the same example, how would you report these services if everything occurred 4 months after the original surgery performed by your partner?

If you see the patient 4 months after your partner performed the original ACL reconstruction, the E&M service, the joint aspiration, and the arthroscopy would all be separately reportable. You would append a modifier 25 to the E&M service to indicate a significant separate service, protecting it from being bundled into the aspiration. The office aspiration and the arthroscopy would both be reported without modifiers because they occur outside the global period initiated by the original surgery.

The key to understanding how to report services when you are seeing your partner’s patient in the postoperative period is to report the service exactly as your partner would if he or she delivered the service personally. It is important that your partner also understands this convention.

Margaret M. Maley, BSN, MS, is a consultant with KarenZupko & Associates, a Chicago-based practice management company with more than 25 years of experience working with orthopaedic surgeons and their staff.