Physician Practice

Q&A: You've got questions! We've got answers!

Physician Practice Insider, September 4, 2017

Question: I work for a group of general surgeons. Quite often, our patients are brought back into our office and taken to our patient rooms, where a surgeon may perform an incision and drainage of a hematoma or a seroma. I have considered these “procedure rooms” since we do procedures here at the office and I have been billing the visits with a 78 modifier. Now I am told that the 78 is used only if the patient is taken back to the hospital operating room. Can you provide clarification on this situation?

Answer: Due to conflicting policies from payers, you’ll want to tread lightly with your return-visit procedures for which modifier 78 (Unplanned return to the operating/procedure room for a related procedure during the postoperative period) might be appropriate. 

However, note that one constant runs through most payer policies — a “patient room” does not qualify as an eligible site for a return surgical procedure. CMS may have the most stringent policy, for which you should avoid the office suite altogether when reporting post-surgical complications involving a second procedure.

“Medicare will not pay for initial complications treated in the office [place of service 11] in a global package,” advises Margie Scalley Vaught, CPC, Coding Pro technical adviser. CMS will pay for postoperative complications that require a return trip to the operating room (OR), and in that case you can apply modifier 78 to get your claims through.

However, take heed of CMS’ specific definition of what constitutes an eligible procedure room. “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,” states CMS in its global surgery fact sheet (see resources, below).

Medicare also explicitly rules out certain places of service. An appropriate site for a post-operative procedure “does not include a patient’s room, a minor treatment room, a recovery room or an intensive care unit,” states CMS.

You may find looser policy among your private payers that adhere to CPT guidance on modifier 78 and don’t maintain as narrow a definition of an operating room as CMS. The definition of modifier 78 specifically names a “procedure room” as an eligible site, and if your practice has a dedicated room for procedures you could justify the service with a 78. — Richard Scott (rscott@decisionhealth.com)

Resource:

Global surgery fact sheet: www.uth.edu/dotAsset/1f8ac0da-6fa7-423c-8c0e-cf7cb490a285.pdf

 

Editor’s note: Email your questions to Editor Karen Long Rayburn at klong@decisionhealth.com.

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