Wiki E/M same specialty, different practices

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coderbeth

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How do we handle this?

Some of our physicians are general surgery. Sometimes we perform all of the aspects of care during the patient's stay such as the inital visit, the surgery with follow up care.
Sometimes, a different general surgeon from a different group performs the initial visit and surgery, and when we are on call during the week or weekends, we follow up with the patient, so I figured I would bill for this visit, knowing they are in a global for the surgery, but the patient's surgery was not performed by us. When we bill these charges out, we are hit with the denial "Benefit for this procedure/service is included in the payment/allowance for another service/procedure that has already been adjudicated.

I have researched and researched. I can not find anything that addresses this problem. I am wondering how other practices handle this. If we see that the patient is seen by a different surgeon in a different practice and the patient had surgery with the other surgeon, do we just cut our loses? That doesn't even seem fair. Is there another modifier that we can use? Can we use 27 modifier?

If you have input, I welcome it.

Thanks so much

Beth
 
Since all of the routine post-operative care for a surgery is included in the global payment, it sounds like these denials are correct if the original surgeon was paid in full for the surgery. Medicare, and payers that follow standard global surgery reimbursement, will allow the surgical package to be separate when a transfer of care occurs, by use of modifiers 54 and 55 on the surgical code to pay for the intra- and post-operative portions separately (see page 8-9 of the Global Surgery booklet here for additional details: https://www.cms.gov/Outreach-and-Ed...oducts/downloads/GloballSurgery-ICN907166.pdf). But it sounds like that is not the situation in your case if your surgeons are just covering for each other for post-operative visits and not actually transferring care. Medicare, in the above reference, does state that if "a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate E/M code. No modifiers are necessary on the claim," but if you are getting denials, then this is not being followed and you might wish to try appealing citing this as a reference. However, if this is a frequent and not just an occasional thing, then this is probably not a good solution, and in any case, it's not really appropriate to be routinely billing for something that was already paid to another practice - although it's 'unfair' that your physicians aren't reimbursed for this work, it would be equally unfair to bill the patients and their plans for a service that was already paid for.

Other than to split the global package or to appeal, I think your only option is to make an arrangement with the other physician's office to get compensation. If the two practices are covering each other in approximately equal amounts, it may be simplest just to let these go and not worry about it. But if not, you might want to come to an agreement with the other practice where both offices track the post-operative services that each is performing and then periodically compensate the other for an agreed-upon amount. This is the way that practices I've worked with handle this situation - they'll either just 'trade' the services as a gesture of good-will and cooperation, or they'll make an agreement to reimburse each other for the amount of work that is done. I'd suggest talking to your manager or providers about approaching the other practice so that they can come to such a solution as to how they want to handle this.
 
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