Medicare Guidelines: Treatment of Postoperative Complications

Plus, know more about Modifier 78 in particular

If you have complications in your postoperative period, this should be noted and separately reported and actually coded. So, when you are billing the treatment of postoperative complications, you should ask yourself these medical coding questions:

What insurance does the patient has?  You should know whether it's Medicare or non-Medicare. You should know the global period because the global period will tell you whether you need modifiers to bill for services. You must know is it a 0 or a 10 or a 90-day global.

And then the location, did you treat the patient in the OR? Was this patient brought back to the OR for treatment of these complications in the OR? Did you do it in the office? Did you do it in the Emergency Room or did you do it at the bedside?

In the treatment of postoperative complications, when you do treat – treatment of postoperative complications, modifiers are needed for services that are performed in the global period. If these services are medical, you should use modifier 24. If these services are surgical, use either modifier 78 or 79 as per updated Medicare guidelines.

Now, when we look at Medicare, Medicare copays for treatment of postoperative complications only when you had to bring the patient back to the OR and then you should use modifier 78 if you're in the global period.

That means that Medicare says, “Look, if you take care of a complication out of the OR, it can't be too bad. We're not going to pay you for that. But if you have to take the patient back to the OR, then it must be a more serious complication because he needs more surgery. We will pay you for that. But to get it paid in the global of the initial procedure that brought on the complications, you must append modifier 78.”

Private carriers including most HMOs and most private carriers will pay for postoperative, the treatment of postoperative complications in all locations.

If you bring the patient back to the OR in the hospital just like Medicare, use modifier 78. But if you take care of a complication medically in the office, see that's not a smooth convalescence. As the CPT code says, you could bill for that. You need a different diagnosis and you'd have to use modifier 24.

If you surgically treat the patient in the office for a complication in private carrier, then you can bill for that. If you have a new diagnosis and the private carrier say, “Give us modifier 79 to indicate that this was not a smooth convalescent cause.” And you had a complication that you had to treat in the office with modifier and use modifier 79.

Modifier 78

Modifier 78 is for an “unplanned” return to the OR. The new word that they added was “unplanned” return to the OR. And they added also this year “procedure room” to correct the complication by the same urologist in the postoperative period.

Again, you'll need a separate diagnosis indicating that complication different from the reason for the surgery. 78 is appended to the surgical code only. And you will only be paid when you use 78 the intraoperative portion of the global fee. You won't be paid for the pre and postop. That, they feel is included in the first surgery. Now, you will also not get a new global period imposed upon you with the second procedure. You will still fall under the global of the original surgery.

Medical Coding Scenario: Let's look at the postoperative complication, this is the Medicare EOB. On 06/03, this patient underwent ESWL for large pelvic stone. In passing the stone, the patient had (steinstrasser) where all the stone fragments block the ureter producing pain and obstruction and producing a complication from the ESWL.

On 06/18, the patient was taken to the OR where the patient underwent the ureteroscopic lithotripsy and the placement of the (JJ) stent. And these procedures were done in the hospital operating room.

As this is a Medicare patient, you see that the ureteroscopic lithotripsy, the 52353, was paid with modifier 78 and that the placement of the stent, the 52332, 78 also modifier was paid.

Notice that we do not need now modifier 59 on the 52332 because the placement of the stent, 52332, that code had been unbundled, that's been removed from the bundle, it's not bundled into any of the ureteroscopic codes.

Let's look at some other treatment of postoperative complications. Here we have a bladder neck contracture complication after a radical retropubic prostatectomy.

Now, the radical retropubic prostatectomy was performed on day one, 55845 diagnosis carcinoma in the prostate 185. On day 37, the patient comes in with a poor urinary stream and a weak urinary stream, ICD diagnosis 788.62.

You examine the patient and then you did a cysto and a dilation of the bladder neck and the insertion of the catheter. That's all included in 52281.

Now, for private carriers, this represents a complication in the postoperative global period that you treat in the office. So, the visit, you need modifier 24 to indicate that it should be paid in the global of the 55845.

You need modifier 25 because on the same day you are doing a cysto and urethral dilation, 52281. And because this code, the 52281 is in the global of the 55845 private carriers tell us, use modifier 79 so you get paid as per medical coding rules.

Now, Medicare will not pay any of those services after the radical prostatectomy because their surgical package includes the treatment of complications outside of the OR. On day 45 when you brought the patient back to the OR to incise the bladder neck contracture, you use the code for both Medicare and private, the 52276 with modifier 78. This is the treatment of a complication in the OR. It's the Medicare and private.

Notice that for the incision of the bladder neck contracture, we use the code 52276. This is the code that represents the internal obstacle urethrotomy. The pathology is a stricture at the urethro-vesical junction. It's a structure of the urethra consequently its cutting should be described using the medical coding and billing option 52276.

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