post operative complications

Good morning.

We were advised from an outside audit that modifier -78 can be used for a post op procedure in the office.

Example: patient had a mastectomy and developed a seroma in the postoperative period. Physician is wanting to bill CPT 10140 (drainage of a seroma) that was performed in the office (no treatment room etc)

After review of modifier -78 fact sheet from WPS I am not comfortable adding a -78 modifier to 10140.

Anyone else agree/disagree?

Thank you.



Lisa Hook, CPC, LPN

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Comments

  • edited June 2017
    That would be incorrect information from your outside auditor. The best
    you can do is bill the procedure with a post op complication diagnosis and
    appeal when it gets denied as in the post op period.

    Years ago as the AAPC liaison to the AMA, I had discussed with the
    Director of Coding the need for a post op complication modifier that does not
    require a return to the operating room. It was brought up at the coding
    committee and they decided they did not like the term "complication" and thus
    tabled the issue.


  • edited June 2017
    I respectfully disagree.  What you have described, Jan, is accurate for "years ago".  However, in 2011, AMA put a new qualifier onto modifier 78 that now includes a return to OR *or* procedure room.  They've not specified what a "procedure room" means except to say that it's a room in which procedures are performed.
    I believe in the scenario that was presented, it's appropriate to add the modifier 78 to 10140 because the procedure was related to the first done during the Global, it was a complication and it was a return to a "procedure room."
    Following is a snippet from CPT Assistant Aug 2011:

    "Modifier 78

    The phrase "or other qualified health care professional" was added to the title of modifier 78, 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. There are instances when it may be necessary to indicate that another procedure was performed during the postoperative or global period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first procedure, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.)

    Use of Modifier 78

    1. Modifier 78 is added to the procedure when the procedure is related to the initial procedure and requires the use of an operating or procedure room.

    2. If a complication does not require return to the operating or procedure room, modifier 78 is not applicable."
     Leslie Johnson, CPC

    Know what you know & Know Why you Know It!
  • edited June 2017
    How is this a procedure room? My understanding was a procedure room was a dedicated room within the clinic or facility not just an exam room. This sounds like it was just done in the exam room.

    Ruby Woodward
    Sent from my iPhone

  • edited June 2017
    I am well aware of AMA's change in wording however they also at that time
    clearly indicated a procedure room must be a room dedicated to performing
    only procedures not regular office visits. I was in attendance at the
    Symposium where they introduced the "wording change and the intent. Unless it is
    stated as having been done in a "procedure" room you are risking money
    being taken back.


  • edited June 2017
    Exactly Ruby.


  • edited June 2017
    Hey Jan, Hey Ruby,
    What they say in the symposium is helpful to know - however, how would you look at something like this?  Unfortunately, without such a directive in writing, that's like saying "everybody knows..." and how often do we hear something like that, right?  So far, there's nothing in writing - unless you know something I don't, which we all know is entirely possible.
    Most physicians have a "procedure room" whereby minor procedures can be done.  I worked with one physician who would do things from removing skin tags to performing vasectomies.
    Check this out from Empire Blue from 2016, Pg 2 in the link below.
    "Services included in the global surgical package may be furnished in any setting (e.g., hospital, " ambulatory surgical center, or physician’s office). "
    Also see Item #5, page 4
    https://www11.empireblue.com/provider/noapplication/f5/s4/t0/pw_g293730.pdf?refer=ehpprovider
     It is interesting to know that Ophthalmology Management from 2012 declares "minor surgeries" to not be included and yet Empire Blue says yeah, 10140 is payable with modifier 78 during post op - and doesn't differentiate between OR and "procedure room." 
    Palmetto doesn't specify, although it states what an OR is *not*:  http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Railroad-Medicare~8EEL9G2466
    Although not authoritative, Supercoder has a thing or two to say also:  https://www.supercoder.com/my-ask-an-expert/topic/modifier-78-what-is-the-definition-of-procedure-room
    Could this be a payer-specific kind of thing? I'm not convinced.  What do you have that substantiates your assertion?  Great discussion!
    Leslie Johnson, CPC

    Know what you know & Know Why you Know It!
  • edited June 2017
    Ruby, it wasn't told to us by the original poster what kind of room the procedure was done.  Dedicated vs. non-dedicated?  Most physicians I've worked with do have a type of exam room where minor-ish procedures are done vs. the routine sick visit.
    I suppose that's something we should ask the original poster, yeah?   
     Leslie Johnson, CPC

    Know what you know & Know Why you Know It!
    -
  • edited June 2017
    All I have is the definition of the modifier which even in the CPT assistant info it says performed in the OR/procedure room.

    I agree that many provider's offices have a procedure room. Many also do not.

    The original note, although it doesn't specify where implies it was not done in a procedure room since Lisa says in parenthesis no treatment room etc.

    If I was going to have to defend the location based upon the modifier definition I would want to see clear documentation of the patient being taken to the procedure room and then the procedure note.

    Ruby Woodward
    Sent from my iPhone

  • edited June 2017
    And I do love the discussion.

    Ruby Woodward
    Sent from my iPhone

  • edited June 2017
    I would be sooo Interested in the clarification of ‘procedure room’ for physician practices…….and, how that plays out in:



    DOCUMENTATION.



    Does the auditor make the decision based on the patient prep and anesthesia?



    To me, that would be the only way they could determine the actual placement of the patient was in a room dedicated only to procedures, short of an on-site inspection.



    For an office-based practice’s claim this will be very hard to prove under an audit without a site visit. And, that would only be warranted if there was a hint of repeated aberrant billing.



    I can’t tell you how many ‘procedure rooms’ have been used in reverse….for an E/M. Just sayin’



    Karen A. Hurley, BS, CMM, CPC, CNA

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  • Ah, yes – me, too.
  • edited June 2017
    CMS indicates it must be what I call a “sho-nuff” OR – like Jan, I remembered this from the AMA Symposium (I was probably sitting right next to her!) – and I had also found this reference in the Claims Processing Manual – Chapter 12, Section 40.1.B –



    Service Not Included In The Global Surgical Package

    “Treatment for postoperative complications which requires 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);”


    Kim



    Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC

    KGG Coding and Reimbursement Consulting, LLC

    PO Box 1804

    Alabaster, AL 35007

    Phone: 205/621-0966

    Toll-Free: 877/893-5583

    Fax: 781/723-5558

    mailto:kim@kimthecoder.com



  • edited June 2017
    Yes, this is also found in some of the links I provided earlier.  Trouble is, it defines what an OR isn't, not really what a "procedure room" is.  
    Thanks for sharing!!
     Leslie Johnson, CPC

    Know what you know & Know Why you Know It!
  • edited June 2017
    Agreed!!  I'm thinking more information is needed and frankly, I would like to see "procedure room" defined better.  You're quite right - not all doc's offices have that room with all the neat toys & gadgets in it, so again, more information would likely be needed.
     Leslie Johnson, CPC

    Know what you know & Know Why you Know It!
  • edited June 2017
    Hm, I'm not so sure that prep/anesthesia would make a big difference.  If you get staples removed, they'll use a liquid topical (lidocaine) that IMHO doesn't really help a whole lot. Well, maybe a little.  The point I'm making is - lidocaine is a type of anesthetic used in many offices.  It's not considered "anesthesia" in terms of happy gas or anything like that, but it's a topical anesthetic.  
    Ditto with the lidocaine or marcaine ("any -caine") they'll mix with certain medications for joint injections, trigger point injections that are done in an office setting.  If an orthopod injects a patient during the global period of say a joint replacement, we code the injection using modifier 58, but the patient need not go to the hospital.  In what kind of room is this kind of injection done?  I guess I'm thinking "out loud" here.
    I'm thinking that if a room were so stocked with a few various tools & such, it could be considered a "procedure room" - not the "every day" room - although, I would venture a guess that this room would/could also be used for your every day routine E/M visit, too.  Even my dentist has rooms designated for certain purposes, so it's not inconceivable that some physicians' offices would, too.
    I'm not sure how an auditor would look at this kind of thing. Some don't have access to query the physician about such things & even if they did, would it even raise any red flags to go & query?? I do a lot of audits, so I'm not sure it would raise any with me, come to think of it.  I think most auditor might base their decision on the codes themselves unless they were physically on site to ask or unless they were doing a focused audit on the modifier itself since the modifier bypasses most edits payers have in place!  That's a very interesting question & I sure hope we have auditors who are familiar with this kind of scenario speak up on the subject because inquiring minds would really like to know!
    Great stuff to think about!!
    Leslie Johnson, CPC

    Know what you know & Know Why you Know It!
  • edited June 2017
    Agree although I have seen something defining that I just can't remember where

    Ruby Woodward
    Sent from my iPhone

  • edited June 2017
    I don't think anesthesia/prep affects the use of the modifier nor would it really affect the code selection. That in reality is more of a medical legal point. But I would expect something to support the definition of the modifier thus documentation of where it was performed.

    Ruby Woodward
    Sent from my iPhone

  • edited June 2017
    Agree but we don't know if this is Medicare this we need to go with the modifier definition which allows for procedure room. If of course this would be Medicare then it isn't billable based upon the global package definition.

    Ruby Woodward
    Sent from my iPhone

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