Ob-Gyn Coding Alert

In a move to explain what is and isnt included in the global surgical package, CPT 2002 includes new, specific language as to the components of the package. The language is included at the front of the surgical guidelines section under the heading CPT Surgical Package Definition:
 
The services provided by the physician to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. In defining the specific service included in a given CPT surgical code, the following services are always included in addition to the operation:
 
local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
 
subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical)
 
immediate postoperative care, including dictating operative notes, talking with the family and other physicians
 
writing orders
 
evaluating the patient in the postanesthesia recovery area
 
typical postoperative follow-up care.

 
The most significant aspect of the new language relates to the preoperative E/M visit with history and physical. Prior to this, says Melanie Witt, RN, CPC, MA, an independent coding educator from Fredericksburg, Va., and an ob/gyn coding expert, CPT never specified that any E/M services were included in the surgical package. Now they include an E/M service on the day of or day before surgery if it relates to the surgery but is not the visit at which the decision for surgery was made.
 
For example, if a physician conducts a history and physical (H&P) on the patient the day of or the day before surgery, on an inpatient or outpatient basis, the H&P is included in the global charge. Some disagreement may occur when the physician performs the H&P after deciding to do surgery, but performs it more than two days prior to the surgery. The CPT guidelines indicate that the E/M visit (9921x) that occurs more than a day before surgery can be billed outside of the global surgical package. But it remains to be seen whether insurance companies will interpret the new guideline in this manner, or not pay for any preoperative H&P.
 
The physician should still be performing the E/M service that includes H&P in preparation for the surgery in a time frame that is in the best interest of the patient from a clinical perspective, says Philip N. Eskew Jr., MD, medical director of Women and Infant Services at St. Vincents Hospital in Indianapolis, and this may mean that the H&P is done a week before surgery. Eskew feels that rather than schedule the H&P two or three days before surgery, providers should schedule the visit a week ahead to avoid any ambiguity with the carrier. 

E/M and the Decision for Surgery

 
The new language also calls for a heightened awareness regarding the decision for surgery. Modifier -57 (decision for surgery) is appended to an E/M visit where the decision for surgery is made when that E/M visit occurs the day before or the day of surgery. For example, if a patient reports to the office or the hospital with a complaint of severe cramping and bleeding (625.9, unspecified symptom associated with female genital organs; and 626.6, metrorrhagia), the physician might diagnose a missed abortion (634.11, spontaneous abortion, complicated by delayed or excessive hemorrhage, incomplete) and schedule an immediate dilation and curettage (D&C) to complete the abortion (59812, treatment of incomplete abortion, any trimester, completed surgically).  
 
Due to the severity of the patients condition when she presented, the ob/gyn could still charge for a high-level E/M visit (e.g., 99214) with modifier -57 because the surgery was immediate. The E/M encounter with H&P as defined in the new language is bypassed because an H&P was part of the E/M visit when the decision for surgery was made. Because modifier -57 indicates more involved medical decision-making by the physician, the carrier should not take exception to paying for the separate encounter.
 
The flip side to the above example occurs if the ob/gyn treats a patient and schedules surgery more than one day ahead of the procedure. For instance, a patient presents with a complaint of pelvic tenderness (625.9). The physician examines her during a routine midlevel E/M encounter (e.g., 99213) and then schedules an ultrasound. The ultrasound (76830, ultrasound, transvaginal), which takes place three days later, reveals a small ovarian cyst (620.2, other and unspecified ovarian cyst).
 
One week later, the patient undergoes a biopsy with cystectomy (58900, biopsy of ovary, unilateral or bilateral [separate procedure]). Prior to the surgery, which takes place in the hospital, the physician visits the patient and conducts a preoperative H&P as outlined in the new language. Since the encounter at which the decision for surgery was made was more than a week prior, there is no need for modifier -57 and no ambiguity in terms of whether another E/M encounter with H&P is required.

 
If the patient is seen on the day before or the day of surgery for a problem unrelated to the reason for surgery, an E/M service can be billed separately. Add modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service for a same-day procedure. No modifier is needed if the unrelated E/M service occurred on the day before surgery. For instance, the patient has developed a severe vulvar rash (616.10, vaginitis and vulvovaginitis, unspecified) the day before an in-office or hospital surgical procedure. Rather than schedule a separate visit to discuss the problem, she may wait until the day of the procedure to mention it to the physician. Although the condition is not serious enough to warrant a postponement of surgery, a separate, unrelated E/M visit does occur and can be billed with the appropriate code (99212-99215) and modifier -25.