Orthopedic Coding Alert

When different orthopedists in your practice treat a patient during her global surgical period, Medicare often includes their treatment in the global package, even if they did not personally perform the surgery. But this doesn't mean that you should write off all of your practice's treatments, particularly if other specialists within your practice see the patient for a separate procedure.
 
Because all orthopedic surgeons in the practice share the same tax identification number, Medicare considers them the "same" physician, but this doesn't hold true for specialists such as podiatrists, physiatrists, internists, etc.

Use Modifiers to Separate Surgeries

Consider this scenario, submitted by Patti Cox, coder at South Bend Orthopaedics, a 14-physician practice in South Bend, Ind.: Dr. Smith performs an open reduction, internal fixation (ORIF) of a patient's bimalleolar ankle fracture (27814, Open treatment of bimalleolar ankle fracture, with or without internal or external fixation).
 
Forty days later, Dr. Jones, an orthopedic surgeon with Dr. Smith's practice, performs an arthroscopic rotator cuff repair (29827, Arthroscopy, shoulder, surgical; with rotator cuff repair). Because the ORIF carries a 90-day global surgical period, will Medicare bundle the rotator cuff surgery into the surgical package?
 
Yes, unless you append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to 29827, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a Lakewood, N.J., reimbursement consulting firm. Otherwise, she says, the carrier will consider it bundled into the ankle surgery's global period.
 
This is because section 15501H of the Medicare Carriers Manual (MCM) states, "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician."
 
If the same surgeon performs both surgeries, you should append modifier -79 to the second procedure. You should follow that same logic, therefore, if two different orthopedists in the same practice perform the two dif-ferent surgeries.
 
You should note that your carrier will launch a new global period starting on the date that you performed the rotator cuff repair. Even though only 50 days remained on the patient's original global period, she will be under the new global period for an additional 90 days.

Different Specialist, Different Story

In another scenario, let's say a podiatrist in your practice performs a bunionectomy (28290, Correction, hallux valgus [bunion], with or without sesamoidectomy; simple exostectomy [e.g., Silver type procedure]). During his 90-day global period, the patient dislocates his elbow, requiring open repair (24615, Open treatment of acute or chronic elbow dislocation) by an orthopedic surgeon at the same practice.
 
This time, Medicare will not view both physicians as the "same" surgeon, because they practice under different specialties. The MCM states, "Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group."
 
The podiatrist and orthopedist should report their services independently of one another, and each service will carry its own global surgical period.

Not So Fast, Subspecialists

Suppose an orthopedic surgeon in your practice performs a meniscectomy (29881, Arthroscopy, knee, surgical; with meniscectomy [medial OR lateral, including any meniscal shaving]), and then 30 days later your hand surgeon performs an extensor tendon repair (26418, Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon).
 
Because CMS recognizes hand surgery with its own physician specialty code, your carrier will automatically separate the hand surgery from the knee surgery, right? 
 
Wrong, Cobuzzi says. Although some payers will reimburse you for both services based on the different subspecialties, it's not automatic.
 
You should ask your carrier whether it recognizes your subspecialty as a "different" specialty for coding and billing purposes. If not, the carrier will probably include the subspecialist's services in the global surgical package, and you should therefore append modifier -79 to separate the two services.

Two Diagnoses Warrant Two E/M Codes

Now let's suppose your orthopedist performs a level-three new patient office visit (99203) for a patient with lumbar pain. The orthopedist determines that the pain stems from the patient's recent bumpy boat ride and prescribes NSAIDs and rest.
 
During his evaluation, however, the orthopedist discovers that the patient also has a case of carpal tunnel syndrome (354.0), and asks the practice's hand specialist if she can see the patient sometime later that day.
 
The hand specialist performs a level-three office visit and schedules the patient for a follow-up visit. Does your carrier recognize the hand specialist as a valid subspecialist? In this case, it doesn't matter.
 
You aren't dealing with global surgical issues, and the physicians evaluated separate conditions. Consequently, Medicare allows you to separately report both services on the same date.
 
The MCM says, "If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems."

Report One E/M for the Same Condition

If the orthopedist suspects a serious spinal condition and asks the practice's spine specialist to see the patient the same day, you should not report two separate E/M codes, because they evaluated the same problem. Instead, you should combine the two physicians' visits and select an E/M level based on the documentation from both orthopedists.