CODING Q&A Follow-up Questions Regarding Post- operative Care and ‘Established’ Patients ■ DAVID STERN, MD, CPC Q . I was curious about your response to a case listed in Coding Q&A in the November issue of JUCM. The case described a patient who returned for re- opening of a wound due to infection. The physician then cleansed and re-sutured the wound. Although I agree about the postoperative care in general, I wonder if modifier -79 would be appropriate in these circumstances. According to instructions by the AMA, this modifier may be used for circumstances when the service is not related to the original service. The infection of the wound is not part of regular global package services. If they had used the diagnosis of wound infection (a different diag- nosis from the original service) along with the appropri- ate CPT, I wonder if this would have resulted in payment. - Questions submitted by Elaine D. Wade, BSN, CCS-P, Presby- terian Health Services A. What you describe may be a compliant method for obtaining payment for payors not governed by Cen- ters for Medicare and Medicaid Services (CMS) rules. Unless the payor has specified otherwise, you can follow the AMA rules for coding of global services. The AMA guidelines state that only routine follow-up care is included in the global period, so many payors may allow you to bill for additional procedures related to complications that occurred during the global period. In the specified case, the payor was Medicare so all fol- low-up care (including, “complications following surgery, which do not require additional trips to the operating room”) is included in the global period. David Stern is a partner in Physicians Immediate Care, with nine urgent care centers in Illinois and Oklahoma, and chief executive officer of Practice Velocity (www.practicevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at dstern@practicevelocity.com. 34 If the patient was actually taken back to a true “operating room” for a procedure, then one would use modifier -78 (Return to the operating room for a related procedure during the post- operative period) to the procedure code. A “minor treatment room” (i.e., a typical procedure room in an urgent care center) does not qualify as an operating room. CMS makes this point in its definition of an “operating room” in the context of a global period (see www.cms.hhs.gov/manuals/downloads/clm104c12.pdf): An “operating room” is defined as a place of service specifically equipped and staffed for the sole purpose of performing surgical procedures. The term in- cluded a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a pa- tient’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 operating room. What about the use of modifier -79 (Unrelated procedure of service by the same physician during the postoperative period)? Yes, it may aid in receiving payment, and private payors may allow you to use this modifier in this way. However, for CMS payors, modifier -79 is only for proce- dures that are completely unrelated to the original procedure. Procedures that are for treatment of complications of the original procedure are not truly “unrelated” to the original pro- cedure, so modifier -79 does not apply to these procedures. NOTE: The specific question that was addressed indi- cated that the wound was not re-sutured. It was simply opened and rechecked several times. No second procedure was performed. Even so, under the AMA definition of the care included in the global period (but not under CMS rules for the global period), one could code an E/M for each recheck for the complication. Your payor may allow you to use modifier -24 (Unre- JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | D e c e m b e r 2 0 0 7 Continued on page 36. w w w. j u c m . c o m