Key Insights On Post-Op Infection Coding

I had the privilege of being the speaker at the North Carolina Foot & Ankle Society Summer Meeting this month. A hot topic of discussion was how to handle the coding of a post-op infection. Many of the procedures we perform have a 90-day global period. Any care we provide within that global period is included in the payment for the procedure although there are some exceptions.

If you see a patient in a post-op global period in the office with a complication of the procedure for which the patient is in the global period and you perform an evaluation and management (E/M) of that complication, there is no modifier that allows for payment of that E/M. The same is true of any E/M performed in the inpatient setting during the global period. The only E/M modifier you can use during a global period is the 24 modifier, which is only appropriate when the E/M is for a problem unrelated to the one for which the patient is in the global period.

If you perform an unplanned procedure for the aforementioned post-op infection, it is only billable if you perform the procedure in an operating/procedure room and use the 78 modifier. Do not bill procedures related to the problem for which the patient is in a global period (even a debridement of this post-op infection site) if the procedure occurs in the office. The only modifier appropriate for procedures performed in the office during a global period would be the 79 modifier, which is for procedures unrelated to the one for which the patient is in the global period.

The exception to this is the use of the 58 modifier, which is for procedures during the global period that one plans or anticipates (staged), procedures that are more extensive than the original procedure, or for therapy following a surgical procedure.

Dr. Lehrman is on the APMA Coding Committee and is a Fellow of the American Academy of Podiatric Practice Management (AAPPM). Follow him on Twitter @DrLehrman.