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Eli's Rehab Report

Reader Question:

Medicare: Partners Are Same Physician

Published on Tue Jul 01, 2003

Question: One of our physiatrists administered a Botox injection (64614) to a patient with cerebral palsy (343.x). Nine days later, the patient returned, complaining of foot pain due to her Achilles bursitis (726.71). Another physiatrist in our practice administered a bursa injection (20605), but Medicare denied it and claimed it was bundled. The National Correct Coding Initiative (NCCI) does not include any edits that would bundle these codes together, so why was my claim denied?

Arizona Subscriber
 

Answer: Medicare denied your bursa injection (20605*, Arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) because you performed it during the Botox injections global period.
 
Although most practices dont consider Botox injections surgery, 64614 (Chemodenervation of muscle[s]; extremity[s] and/or trunk muscle[s] [eg, for dystonia, cerebral palsy, multiple sclerosis) carries a 10-day global period.
 
A global period, which defines a package of services associated with certain codes, includes pre- and postoperative care.
 
If you perform other services during the global period, Medicare will deny the claims as bundled into the global surgical package unless you append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to the second procedure. This tells the carrier that the second service was unrelated to the initial procedure.
 
Report 64614 linked to 343.x for the Botox injection and 20605-79 linked to 726.71 for the bursa injection.
 
Some practices might question why modifier -79 is necessary, considering that separate physicians performed the two procedures. The explanation: Medicare considers them the same physician because all physiatrists in the practice share the same tax identification number. 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 physiatrist performed the Botox injection, and another specialist, such as a podiatrist or orthopedist, administered the bursa injection, modifier -79 would not be necessary. 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.

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