Pediatric Coding Alert

For proper reimbursement, pediatricians administering post-op care should use a different diagnosis code from the surgeons. Its a fairly common dilemma for pediatricians: A child goes to a surgeon for a procedure, but during the postoperative period comes to the primary-care provider for another problem, which may or may not be related to the surgery.

Often, the insurance company assumes that the new problem is related to the surgery, and it wont pay the primary-care pediatrician for his or her encounter because the encounter takes place during the 90- or 10-day global period. The payment for the surgery is supposed to cover all related care by the same physician during that global period.

Global Period Applies to Surgeon Only

The global fee covers the operating surgeon (in the absence of modifiers -54 [surgical care only] and -55 [postoperative management only]) even if the diagnosis for the postoperative visit is related. If the diagnosis for the postoperative visit is unrelated, insurance companies rarely have a problem paying, and no modifiers are necessary.

A typical scenario follows:

Scenario #1: A urologist performs a circumcision (V50.2 ). Then, the site starts looking infected to the parent. The parent brings the child to the primary-care pediatrician to have it checked because the urologist is two hours away. The insurance company tells the pediatrician that the visit was covered by the global fee for the surgery, and therefore the pediatrician will not be paid.

According to Dari Bonner, CPC, CPC-H, CCS-P, president and owner of Xact Coding and Reimbursement Consulting in Port St. Lucie, Fla., the insurance company should reimburse the pediatrician. It cant be in the global period for the surgery if its a different physician. The global period only applies to the surgeon, says Bonner. This is true regardless of whether the problem the child consulted the pediatrician for is related to the surgery or not. In the above scenario, what looked like an infection could have been diaper rash (691.0), or it could have been an infection of the wound. In either case, the pediatrician should be paid for treating the condition. And the insurance company should, in Bonners words, be corrected.

Bonner notes that her comments are based on reimbursement guidelines, not coding guidelines. CPT tells you that the urologist should be paid for the surgical procedure, and that if the urologist doesnt do the post-op care, the pediatrician should be paid for the post-op care, she says. But in practice, this never happens, because its impossible to track. Technically, co-management would refer to the primary-care pediatrician, in this case, signing up ahead of time to provide all postoperative care on the patient. That is not quite what happened in the scenario. The co-management modifiers (-54 and -55) would not be used in this case, she says. Most payers dont even recognize these modifiers, adds Bonner.

Use Different Diagnosis Code

Laurie Castillo, CPC, president of Physician Coding and Compliance Consulting, based in Manassas, Va., notes that insurance companies look at the diagnosis code to see if a condition is related to the surgery to determine whether the visit is covered under the global fee for the surgery. To make it easier to get claims paid, she recommends using a different diagnosis code from the one the surgeon used. The problem could be related to the surgery, but still not be a part of the postoperative care, she says. It could be a complication or an infection. However, she agrees with Bonner that there should be no problem with reimbursement if a different physician provided the care. If the primary-care pediatrician is denied payment for services rendered during the post-op period of a procedure provided by a different physician, the primary-care physician should appeal, says Castillo.

Scenario #2; Another scenario that represents the global problem is tubes. The ENT does the tubes if a child gets repetitive ear infections, says Jill Von Pier, practice administrator for Crown Colony Pediatrics of Quincy, Mass. But the child still has an earache after the procedure, and comes to see us, and we bill that as an office visit. If the insurance company denies payment, saying the earache is related to the surgery, Von Pier would say, No, its the onset of a new condition, and its not related to the surgery. She would call the insurance company and say, The surgery was done, and the child has presented with a new infection. The tubes do not guarantee that there will be no more infections. I would refile the claim by hard copy, and send a narrative report, she says. It might be necessary to talk to a supervisor to explain this, she adds. I would go to a nurse case managerthey understand what Im saying. Von Pier has also found that if the diagnosis is entirely differentsuch as a sore throatthere wouldnt be the same problem.

Linda Walsh, MAB, senior health policy analyst for the American Academy of Pediatrics, says a good rule of thumb to follow is to code the symptom. ICD-9 codes 780-799 are all for signs and symptoms. These will never be the same as the diagnosis code for the surgery.