Orthopedic Coding Alert

Orthopedic surgeons and their staff who work with residents in a teaching hospital or a teaching setting need to be mindful of a key requirement when it comes to coding and billing. The physical presence of the teaching physician is critical to both maximum reimbursement and legal reporting of physician supervision per the Health Care Financing Administrations (HCFA) requirements for Medicare patients.

HCFA requirements for both emergency department (ED) and regular admits in a teaching setting whether a hospital or a private practice hinge on who is performing the service to the Medicare patient and the creation of the appropriate documentation for the service.

Missed Opportunities to Code for Care

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., with experience coding in teaching hospitals, says, The biggest problem I see over and over is that the teaching physicians dont always make it to the ED. From a coding and billing perspective, they cannot bill for certain services because the services are performed by a resident and not in the presence of a teaching physician.

Callaway-Stradley offers the example of fracture care. If a resident evaluates the patient and provides fracture care (27750, closed treatment of tibial shaft fracture [with or without fibular fracture]; without manipulation) without the appropriate participation and supervision of a teaching physician, no bill can be submitted to Medicare. Nor can a bill be submitted for 99281-99285 (emergency department visit for the evaluation and management of a patient). The hospital could bill for use of the facility and for any supplies not included with 27750, but there is no way legally the facility can bill for a doctors services when none is present.

Callaway-Stradley says that as a result of this initial lack of supervision in the ED, another problem often occurs. When the patient returns to the clinic for follow-up care, the encounter form is marked with 99024 to indicate that a postoperative visit has occurred that is included in the global package for the fracture care. But because no global package has been billed, the visit is billed using regular evaluation and management (E/M) codes 99201-99205 (office or other outpatient visit for the evaluation and management of a new patient). As a result of this confusing situation, some patients could receive a major portion of their fracture care for free because of the lack of adequate supervision in the ED and a lack of communication at the clinic level. This can represent a significant loss in revenue over time. This still boils down to the problem of having the teaching physician actually be in attendance in the ED, adds Callaway-Stradley.

In the case of the follow-up care, Blair Filler, MD, FACS, director [...]