Orthopedic Coding Alert

In a year that has seen the AMA move toward greater specificity in its codes and code definitions, CPT 2002 also includes new, specific language describing the components of the global surgical package. "CPT's new language essentially puts it in alignment with Medicare's global surgical rules," says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J. The language precedes 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. On 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; 
Evaluation of the patient in post-anesthesia recovery area; 
Typical postoperative follow-up care."
E/M Encounter Is Critical Change
The most significant aspect of the new language is that which relates to the preoperative E/M visit with history and physical. Prior to this, 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 the day before surgery if it relates to the surgery as long as that encounter is not the E/M visit when the decision for surgery was made.
 
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 does the H&P after the decision to do surgery is made, but performs the H&P more than two days prior to the surgery. The CPT guidelines indicate that the E/M (9921x) visit that occurs more than one day out from surgery can be billed outside of the global surgical package. It remains to be seen whether individual insurance companies will interpret the new guideline in this manner, or not pay for any preoperative H&P. The physician should still perform the service in a time frame that is in the best interest of the patient from a clinical perspective. This may mean that the H&P is done a week before surgery. In fact, rather than schedule the H&P two or three days before surgery, providers are wise to schedule [...]