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."

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 the visit one week prior to surgery to avoid any ambiguity with the carrier.
 
"The orthopedic practice where I code and bill does not perform many preoperative visits the day before or the day of surgery," says Jennie Horner, CPC, lead biller/coder for Southern Ohio Medical Center, Medical Care Foundation in Portsmouth. She says there are a few exceptions to this, for example, like total hip, shoulder and knee replacements. "For these, the doctor orders extensive lab tests, chest x-rays and reviews all current medications to establish the patient's status as close to the time of surgery as possible due to the length and complexity of these surgeries, as well as the extensive postoperative rehabilitation required." Horner advises office staff to communicate with the physician to determine which patients need preoperative clearance the day of or the day before surgery but not to routinely schedule preoperative visits within two days of the scheduled surgery.
 
Patients often schedule major, debilitating surgeries like total joint replacements months in advance. In these cases, the physician will likely want to see the patient a few weeks before surgery. To avoid any confusion with the payer, this encounter should be coded and documented as a problem-oriented E/M visit (e.g., 99212-99214) rather than a preoperative check. 

E/M and Decision for Surgery

The new language will also require orthopedic coders to pay close attention to the decision for surgery visit. Modifier -57 (decision for surgery) is appended to an E/M visit where the decision for surgery is made, when that visit occurs the day before or the day of surgery. For example, a patient reports to the hospital with a fractured femur (e.g., 821.11, fracture of other and unspecified parts of femur; shaft). The orthopedist immediately takes the patient to the operating room for an open reduction with internal fixation (27248, open treatment of greater trochanteric fracture, with or without internal or external fixation). Given the severity of the patient's condition when she presented, the orthopedist could still charge for a high level E/M visit (in this case, 99283-99284, emergency department visit for the evaluation and management of a patient ) with modifier -57 since 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 encounter when the decision for surgery was made. Because modifier -57 indicates more involved medical decision-making on the physician's part, the carrier should not take exception to paying for the separate encounter. "The decision for surgery shouldn't be impacted by this new language," adds Brink, "but coders should be aware that they can still append modifier -57 where appropriate."
 
The flip side to the above example occurs if the orthopedist treats a patient and schedules surgery more than one day out. For example, an established patient reports with a complaint of severe knee pain (719.46, pain in joint, lower leg). The physician examines him during a routine mid-level E/M encounter (e.g., 99213), and schedules an MRI to diagnose the problem. The MRI, which takes place at the earliest available appointment three days later, reveals torn medial meniscus (836.0, tear of medial cartilage or meniscus of knee, current).
 
One week later, the patient undergoes an arthroscopic medial meniscectomy (29881, arthroscopy, knee, surgical; with meniscectomy [medial or lateral, including any meniscal shaving). Prior to the surgery, which takes place in the hospital, the physician visits the patient and conducts a preoperative H&P. 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. Horner adds that the CPT language changes require not only the medical and billing staff to be educated and trained as to the "intent" of the visit, but the practice staff that schedule patients should be familiar with the different types of visits as well.

If the patient is seen 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, adding modifier -25 (significant, separately identifiable E/M 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 or no modifier if the unrelated E/M service occurred the day before surgery. For instance, the patient has developed shoulder pain on the day she is seen to go over orders for her scheduled, elective knee surgery. 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 99212-99215 and modifier -25. Make sure that a separate diagnosis is also reflected to show this was a separate service and not a preoperative visit.