Neurosurgery Coding Alert

What should you do when your physician treats a patient during the global period of a procedure performed by another surgeon in your practice? If you think payers dictate that you must "write off" such visits, you're missing out on deserved reimbursement, particularly if a physician of another specialty within your practice sees the patient for a separate procedure.

Because surgeons in a group practice typically share the same tax identification number, Medicare considers them the "same" physician for billing purposes. This means 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 indicate the independent nature of the procedures.

For instance, Dr. Jones performs spinal repair 63056 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root[s] [e.g., herniated intervertebral disk], single segment; lumbar [including transfacet, or lateral extraforaminal approach] [e.g., far lateral herniated intervertebral disk]) on a 48-year-old male patient. Nine weeks later, the patient falls at home and injures an adjacent spinal level. Dr. Smith, of the same group practice as Dr. Jones, performs the second repair 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 herniated disk repair surgery into the surgical package.

In fact, Medicare will bundle the second spinal repair into the global period of the first spinal repair unless you append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to the second procedure, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a Lakewood, N.J., reimbursement consulting firm. As section 15501H of the Medicare Carriers Manual (MCM) explains, "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 patient's original global period, the payer will begin a new global period for an additional 90 days, she says.

If two surgeons in your group practice of different specialties attend to the same patient during a global period, you do not need to use any modifiers to separate the services.

Returning to the above example, for instance, let's assume the patient did not suffer a second spinal injury, but instead damages his left rotator cuff during the fall. Dr. Doe, an orthopedic surgeon with the same practice as Dr. Jones (who repaired the patient's spine), 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 neurosurgeon 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 subspe-cialists 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. In addition, "taxonomy codes" (i.e., specialty categories) will become standardized under HIPAA (for a list of taxonomy codes, go to www.wpc-edi.com/codes/Codes.asp). Therefore, you should determine whether your carrier recognizes a particular subspecialty prior to billing (and ensure that your physician is listed under the correct specialty). If the payer does not recognize the subspecialty, you still have the option of appending modifier -79 to separate the two services.

When coding E/M services, report only one service 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 neurosurgeon evaluates a patient complaining of low-back 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 back pain and schedules a follow-up visit for further diagnostic testing, but also sends the patient across the hall to consult with a neurologist in the same group practice about the muscle weakness (728.9) and loss of sensation (782.0).

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" [emphasis added], according to the MCM. 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 neurosurgeon finds that what the patient initially described as "low-back pain" seems more related to a prior leg injury that causes the patient to limp, and he sends the patient to see the orthopedic surgeon in the same practice. 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 (for instance, 99215). Even in different practices, this could result in one physician's charges being denied as concurrent care.