General Surgery Coding Alert

How can you code if a physician in your group practice treats a patient during the global period of a procedure performed by another surgeon in the practice? If you think that payer guidelines dictate that you must write off such visits, youre missing out on deserved reimbursement, particularly if a physician of another specialty within your practice sees the patient for a separate procedure.

Use Modifiers to Separate Surgeries

Because surgeons in a group practice typically share the same tax identification number, Medicare considers them the same physician for billing purposes. This can mean that you may be unable to bill for subsequent surgeries during a global period for surgeons of the same specialty, unless you use modifiers correctly to unbundle the procedures.
 
For instance, Dr. Jones performs hernia repair (49560, Repair initial incisional or ventral hernia; reducible) on a 48-year-old male patient. Nine weeks later, the patient  overdoes it during a softball game at a family reunion, causing the hernia to recur. Dr. Smith, of the same group practice as Dr. Jones, performs the second repair (49565, Repair recurrent incisional or ventral hernia; reducible)
during the global period of the initial surgery. Because the initial repair carries a 90-day global surgical period, you might guess that Medicare will bundle the second hernia repair surgery into the surgical package.
 
In fact, Medicare will bundle the first and second hernia repairs unless you append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to 49565, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a Lakewood, N.J., reimbursement consulting firm. Otherwise, she says, the carrier will consider it bundled into the global period of the first hernia repair surgery. Section 15501H of the Medicare Carriers Manual (MCM) specifically states, Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. 
 
If the same surgeon performs both surgeries, you should append modifier -79 to the second procedure. You should follow that same logic, therefore, if two different surgeons in the same practice perform the two surgeries. Also, your carrier will launch a new global period starting on the date that you performed the recurrent hernia repair, says Dianna Hofbeck, RN, CCM, ACFE, president of North Shore Medicine Inc., a national billing service in southern New Jersey. Even though only about 30 days remained on the patients original global period, he will be under the new global period for an additional 90 days, she says.

Modifiers Arent Necessary for Different Specialists

If two surgeons in your group practice of different specialties attend to the same patient during a global period, you need not use any modifiers to separate the services.
 
Returning to the above example, lets assume the patient did not cause a recurrent hernia during his softball exploits, but instead damaged his left rotator cuff while sliding into home plate. Dr. Doe, an orthopedic surgeon with the same practice as Dr. Jones (who repaired the patients hernia), performs the rotator cuff repair.
 
This time, Medicare will not view both physicians as the same surgeon, because they practice under different specialties. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group, the MCM states.
 
In this case, the general surgeon and orthopedist should report their services independently, and each service will carry its own global surgical period, Hofbeck says.
 
But not all payers will automatically recognize subspecialists (for instance, a general surgeon and a surgical oncologist or bariatric surgeon) in the same manner. The subspecialty would need to be recognized as such by your carrier, Cobuzzi says. Although this is a Medicare policy, many commercial carriers follow the same standard. Therefore, you should determine whether your carrier recognizes a particular subspecialty prior to billing. If the payer does not recognize the subspecialty, you still have the option of appending modifier -79 to separate the two services, as in the first example above.

Report One E/M for Same Condition

When coding E/M services, report only one code even if two different specialists in the same group practice see the patient, as long as they are evaluating the same condition. If, however, the two specialists are evaluating different, unrelated problems, you may report an E/M visit for each specialist, Hofbeck says.
 
For example, the general surgeon evaluates a patient complaining of abdominal pain, but during the same visit the patient mentions progressive muscle weakness and loss of sensation in the limbs. The surgeon provides an E/M related to the abdominal pain and schedules a follow-up visit for further diagnostic testing, but he also sends the patient across the hall to consult with a neurologist in the same group practice about the muscle weakness and loss of sensation.
 
In this case, each physician is evaluating a distinct complaint. Consequently, Medicare allows you to report both services on the same date. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems, the MCM says. You should report a separate E/M service, as supported by documentation, for each physician.
 

In a second scenario, after some questions and a quick examination, the general surgeon finds that what the patient initially described as abdominal pain seems more related to lower-back problems, and he sends the patient to see the orthopedic surgeon two doors down in the same office. In this case, you should not report two separate E/M codes because both physicians evaluated the same problem. Instead, you should combine the two physicians visits and select an E/M level based on the collective documentation.