Orthopedic Coding Alert

Want to avoid OIG scrutiny in 2004? Check consults and modifiers

Do you append modifier -59 every time those pesky NCCI edits bundle your services into one another? After the release of the OIG's new Work Plan, you'd better make sure that your services are indeed separately identifiable - and that you've got the documentation to prove it.
 
The U.S. Office of Inspector General (OIG) recently released its 2004 Work Plan, and as in prior years, the OIG intends to scrutinize consultations, high-level E/M claims, use of modifiers -25 and -59, incident-to services, certificates of medical necessity, medical necessity of durable medical equipment (DME), and care plan oversight, among other services.
 
Although the Work Plan includes 90 pages of the OIG's 2004 intentions, orthopedic practices are particularly at risk in two areas:

1. Distinguish Consults From Transfers of Care. Medicare paid $2 billion in 2000 for consultations, and now the OIG wants to determine whether practices are reporting these codes (99241-99263) appropriately.
 
The most common consult billing error in orthopedic practices involves patients referred to your practice after a visit to the emergency department (ED). If an ED physician treats a patient for a finger laceration, diagnoses a flexor tendon laceration, and refers the patient to your practice for definitive treatment, you should report an outpatient E/M code (99201-99215), not a consult.
 
Because the referring physician diagnosed the injury and asked you to assume care, your visit does not qualify as a consultation. A consultation requires that the requesting physician ask for your orthopedist's opinion and that your practice write a report back to the requesting physician explaining your interpretation of the patient's condition and your recommendations for care. Most of the time, however, a patient whose care begins in the ED and is transferred to an orthopedic practice qualifies as a transfer of care. Keep in mind that once a patient is discharged from the ED, the ED physician's involvement in the care of the patient ends.
 
Section 15506 B of the Medicare Carriers Manual defines a transfer of care: "When the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance. The receiving physician would report a new or established patient visit ..."

 2. Use Modifier -59 With Caution. The new Work Plan may cause trouble for those practices that submit many claims with modifier -59 (Distinct procedural service). The OIG intends to "determine whether claims were paid appropriately when modifiers were used to bypass National Correct Coding Initiative (NCCI) edits," according to the report. Although several modifiers - including -78 (Return to the operating room for a related procedure during the postoperative period) and -79 (Unrelated procedure or service by the same physician during the postoperative period) - can separate services bundled by the NCCI edits, orthopedic practices usually use modifier -59.
 
"Physicians should be aware that when they append modifier -59, they are representing the fact that they have documentation on file that supports using it," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. "Therefore, you should always be prepared to submit additional documentation that demonstrates that your procedures were separate and distinct from one another." If your documentation won't prove the separate nature of the bundled services, Jandroep says, don't append modifier -59.
 
The OIG Work Plan includes information about all of its investigative focus areas for 2004. You can access the full 90-page document by visiting the OIG's Web Site at http://oig.hhs.gov/publications/docs/workplan/2004/Work%20Plan%202004.pdf.