Primary Care Coding Alert

Although family practitioners (FPs) rarely perform major surgery, they do conduct minor surgery and manage pre- and postoperative services. To avoid miscoding a service, it is important to know what is included in the global period, the normal follow-up care for surgery and what falls into postoperative careespecially if during the post-operative period the patient suffers from problems unrelated to the surgery.

According to Medicare, a global surgery package includes preoperative, interoperative and postoperative serviceswith the postoperative period varying depending on the type of surgery, says Emily Hill, a physician assistant and president of Hill and Associates, a coding and compliance consulting firm in Wilmington, N.C. Although the postoperative care is included in the global package, you should know the incidents where those services fall outside.

Thomas Kent, CMM, principal of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, Md., cites a rule of thumb about global days, normal care follow-up after surgery. If no incision is made, there are zero global days; if a minor incision is made 10 global days are allotted; and for major incisions the global period is 90 days. He also points out that orthopedic procedures carry 90 global days, whether an incision is made or not. If in doubt about what constitutes a global period, contact the Health Care Financing Administration (HCFA) at 410-786-6830.

Different scenarios illustrate how confusion may arise over whats included in the global period and what services fall into postoperative care.

Scenario #1: After an examination with his family practitioner (FP), a 70-year-old patient with hypertension needs bladder surgery to remove a tumor. Since he lives in a small town, the patient is sent to a surgeon in the nearest larger city, where there is a tertiary care center. Once the surgeon has deemed the surgery necessary, the surgeon requests that the family physician conduct a preoperative examination to ensure the patient can withstand anesthesia. Medicare will pay if the exam proves to be a medical necessity, which in this case would likely be due to the patients hypertension.

The FP should code 99241-99245 (office consultation for a new or established patient) for the preoperative evaluation requested by the surgeon. Kent says that many FPs dont realize its a consultation and instead code for an office visit. In addition to the consultation code, the FP should use three diagnostic codes402.91 (hypertensive heart disease, unspecified, with congestive heart failure) for the systemic problem; 223.3 (benign neoplasm of kidney and other urinary organs, bladder), the reason for the surgery; and V72.81 (preoperative cardiovascular examination), the reason for the physical exam. Alternatively, if the patient has no other problems, the FP would code 223.3 and V72.84 (preoperative examination, unspecified). Kent warns that Medicare may not pay for the V code.

After the surgery, the patient returns to the care of his FP. The surgeon should have coded 51530 (cystotomy; for excision of bladder tumor) with modifier -54 (surgical care only). The FP codes the same surgical procedure but with modifier -55 (postoperative management only). The postoperative care can only be billed once despite the number of visits for normal recovery during the 90-day global period. If the FP sees the patient more than once during the global period, Kent says, he or she may want to use 99024 (postoperative follow-up visit, included in global service) just for their own records since the service is not payable.

To ensure that you get paid, Kent recommends communicating with the surgeon, who did not do the postoperative care but may try to code for the global package; otherwise, it may be difficult to get paid.

Hill reminds FPs that they can bill the surgical code plus modifier -55 the first time they see the patient and not wait until the end of the global period. She also says that some commercial carriers do not recognize modifiers, but FPs should still attach the modifier to give the carrier a full picture of services rendered. Kent recommends being a bit more aggressivesimply ask the carrier how you can get paid for your services.

If the patient develops complications not related to the original surgery, such as rapid heart beat, the FP can code an office visit 99213 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) or higher, depending on the complexity of the problem, and 785.0 (symptoms involving cardiovascular system, tachycardia, unspecified).

Scenario #2: An established 10-year-old male patient burns his hand when hot oil spills. The minor surgery would have no global days attached. The first visit would be coded 16020* (dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small) and 944.28 (burn of wrist[s] and hand[s], blisters, epidermal loss [second degree]; multiple sites of wrist[s] and hand[s]). If the FP wants to ensure that the child was not hurt beyond the burn, he may choose to do an office visit, 99212-99215 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: ranging from a problem-focused to a comprehensive history; a problem-focused to a comprehensive examination; and straightforward medical decision-making to one of high complexity) with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached.

Subsequent visits to change the dressings should be coded 16020* for each day the patient returns. First, Medicare considers most starred procedures have 0- to 10-day global periods (most are 0 days). This means care may be billed on consecutive days, Kent says. Second, the starred procedures stand alone with no other procedures bundled into them. Third, starred procedures often have office visits associated with them to evaluate possible associated injuries.

Note: Starred codes indicate that service includes the surgical procedure only.

If on the third day of the childs visit, he developed a wound infection, the FP would code 882.0 (open wound of hand except finger[s] alone; without mention of complication); 99213 and modifier -25, if he prescribed an antibiotic for the infection; and 16020*.

Scenario #3: A surgeon admits an established
62-year-old female patient with diabetes into the hospital for liver surgery, but the family physician performs the preoperative clearance examination at the request of the surgeon. The FP would code 99251-99255 (initial inpatient consultation for a new or established patient, which requires these three key components: ranging from a problem-focused to a comprehensive history; a problem-focused examination to a comprehensive one; and straightforward medical decision-making to one of high complexity).

The FP also assumes responsibility for postoperative care when there are no complications related to the surgery. The patient remains in the hospital for two days because of complications related to her diabetes. The FP may code 99231-99233 (subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: ranging from a problem-focused interval to a detailed interval history; a problem-focused to a detailed examination; and medical decision-making of low to high complexity) for this care.

If the patient, however, is new to the FP and it is determined the postoperative patient has particularly high blood pressure, Hill says it may be appropriate to bill 99251-99255 (initial inpatient consultation for a new or established patient, which requires these three key components: ranging from a problem-focused to a comprehensive history; a problem-focused to a comprehensive examination; and straightforward medical decision-making to one of high complexity). She says, however, that the FP cannot bill for a postoperative consultation if he or she did the preoperative clearance consultation. If postoperative consultation is coded, subsequent visits by the FP to the hospital should be billed by using 99231-99233.

Scenario #4: A 40-year-old established female patient sustains a fractured finger which the FP sets and codes as 26720 (closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each). If the FP is concerned that the patient may have other injuries, he or she may perform an office visit, 99212 with modifier -25. During the 90-day global period, the patient returns with a cold so now the FP codes 99212 with modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period).

Instead of a cold, the same patient falls down and is cut on the arm during the global period for her fractured finger. Since the FP did the original surgery, the family physician should use 12002 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet], 2.6 to 7.5 centimeters); modifier -79 (unrelated procedure or service by the same physician during the postoperative period). Family physicians dont recognize unrelated care and forget to bill for it, says Joy Newby, LPN, and president of Joy Newby and Associates, an Indianapolis-based reimbursement and accounts receivable consulting firm. They often dont realize whats included in the codes they bill. She also reminds FPs that if the original finger surgery was done by another surgeon, modifier -79 is unnecessary.