# Subsequent vis after Consult



## Coder708 (Apr 1, 2009)

One of our dr's are meeting high level consults in the hospital but then doing 3-5 subsequent visits before surgery.  It's just not sitting right with me. IS a sub vist allowed to be billed after a 99255?


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## LLovett (Apr 1, 2009)

I agree with you on this one, it doesn't sit well with me either. I have a question into Medicare based on a statement in one of their policies.

"30.6.6 - Payment for Evaluation and Management Services Provided During Global Period of Surgery
(Rev.954, Issued: 05-19-06, Effective: 06-01-06, Implementation: 08-20-06)
A. CPT Modifier “-24” - Unrelated Evaluation and Management Service by Same Physician During Postoperative Period
Carriers pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT codes 99221-99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT modifier “-24,” and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure. They do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery. All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment."


The last sentence is what makes me question whether those subsequent days are correct. It states all care during the the inpatient stay, not just after the surgery. Maybe someone else will have more info to add...

Laura, CPC


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## FTessaBartels (Apr 1, 2009)

*When's the decision for surgery?*

The way your phrase your post makes me think that it's just *one* doctor in your practice, and that s/he is doing this *consistently*. That really raises a *red* flag if my thoughts are accurate.

In any case ...

What would be the key for me is "when is the decision for surgery made?" 
If the initial consult visit results in a decision for surgery, but the patient isn't stable enough, or needs a course of presurgical antibiotics, or the surgeon can't fit them into the schedule for 3 days ... then I'd say that any  subsequent visits (even though they occur outside the official global period) are part of the surgical package and shouldn't be coded.

On the other hand, if after the initial consult visit there is *no* decision for surgery, but perhaps an order for additional work-up or a "wait-and-see" attitude, then I think that it would be legitimate to have one or possibly more subsequent visits. Once the decision for surgery is made, however, I would not code any more visits until the surgical global period ended. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## AHVC (Apr 3, 2009)

I agree with your post.  Once the decision to operate has been made, the subsequent visits would be considered part of the global component.  If the DTO has not been made and the provider is seeing the patient for subsequent days and there is medical necessity behind these visits, then they should be captured.  If the provider is documenting somewhere along the way that DTO has been made and that he is stilling coding/billing for subseqent days, this is definitely going to be an issue if these records are reviewed/audited.

As we all know, they are now really pushing for "medical necessity" behind billing/coding...There better be the supporting documenting in any medical record supporting the charges.


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## fcalibuyot (Apr 7, 2009)

Great information!! And I totally agree, yet sometimes references are required. With that said, I would kindly as where you got your info from so I could go to that same site and copy/paste for my providers. The providers trust what they can read primarily. Hoepfully you'll respond soon.

Fernando



katmryn78 said:


> I agree with you on this one, it doesn't sit well with me either. I have a question into Medicare based on a statement in one of their policies.
> 
> "30.6.6 - Payment for Evaluation and Management Services Provided During Global Period of Surgery
> (Rev.954, Issued: 05-19-06, Effective: 06-01-06, Implementation: 08-20-06)
> ...


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## LLovett (Apr 7, 2009)

This came from the CMS website.

http://www.cms.hhs.gov/transmittals/downloads/R954CP.pdf

Good luck,

Laura, CPC


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## LLovett (Apr 24, 2009)

In addition to the above policy I posted please see the following

http://www.cms.hhs.gov/Manuals/downloads/clm104c12.pdf

starting on page 88 they define the global package, this seems to contradict the above policy.


Hope this is helpful,

Laura, CPC


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## LLovett (Apr 29, 2009)

*Response from WPSMedicare*

Thank you for the inquiry you sent to Wisconsin Physicians Service (WPS) Medicare regarding billing an evaluation and management (E/M) service after the physician makes the decision to perform surgery but greater than 24-hours prior to surgery. 

The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual, Publication 100-04, Chapter 12, Section 40, explains global surgery. I regret that the above named CMS IOM does not specifically address your scenario. Section 40.1.A, outlines the components of a global surgery package and Section 40.1.B, outlines services not included in the global surgery package. Medicare does not include in the global surgery package E/M services unrelated to the diagnosis for which the physician performs the surgery unless the E/M service occurs due to complications of the surgery. In addition, treatment for an underlying condition or an added course of treatment which is not part of normal recovery from surgery is also not part of the global surgery package. 

Medicare includes preoperative E/M services in the global package after the physician makes the decision to operate. The global period time begins with the day before surgery for major procedures (90-day) and day of surgery for minor (10-day) procedures. However, this section does not mention billing an E/M service after the physician makes the decision to perform surgery but greater than 24-hours prior to surgery. Because more than one day (24-hours) is not mentioned, it appears providers may bill an E/M service separately in this situation. Please remember the provider must document the medical necessary for performing an E/M service. You may access the above named reference on the following CMS Website: 
http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf 

FYI

Laura, CPC


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## hlleary (May 4, 2009)

*Subs. Visits after consults*

I have the same question, I have a surgeon who did an inpatient consult, and then did subsequent visits.  The patient did not have surgery.  The surgeon said he was told that he could not bill for the subsequent visits.  But shouldn't he be able to get paid for following this patient in the hospital also?


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## LLovett (May 4, 2009)

If no surgery was done then there is no global period, he should be able to bill for whatever the documentation supports.

Laura, CPC


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