Primary Care Coding Alert

When your practice provides postoperative care, the key to proper reimbursement is the use of a brand-new diagnosis code.

It's a fairly common family practice dilemma: A patient goes to a surgeon for a procedure, but during the postoperative period comes to the family physician for another problem, which may or may not be related to the surgery. Often, the insurance company assumes the new problem is related to the surgery and won't pay the FP for his or her encounter because it takes place during the 90-or 10-day 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 needed.

For example, a urologist performs a circumcision (V50.2). The site starts looking infected to the mother, and she brings the child into the FP because the urologist is two hours away. The insurance company tells the FP that the visit was covered by the global fee for the surgery, and therefore the FP 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 FP. "It can't be in the global period for the surgery if it's a different physician. The global period only applies to the surgeon," Bonner says. This is true regardless of whether or not the problem the patient consulted the FP for is related to the surgery. 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 FP should be paid for treating the condition. And the insurance company should, in Bonner's 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 doesn't do the post-op care, the FP should be paid for the post-op care," she says. "But in practice, this never happens, because it's impossible to track." Technically, co-management would refer to the primary-care physician, 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 don't even recognize these modifiers, Bonner adds.

Use a Different Diagnosis Code

Laurie Castillo, CPC, CPC-H, CCS-P, president of Physician Coding & 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 FP is denied payment for services rendered during the post-op period of a procedure provided by a different physician, the FP should appeal, Castillo says.

A good rule of thumb to follow is to code for 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.