Ok so I work at a cardiology clinic and we have been getting a lot of denials on hospital visits and office visits that are within the global period for a procedure that was done...they are bundled with the procedure because they are within the 90 day global period...my supervisor is adamant that I add a -24 modifier to them and change the dx codes and "pull the wool" over MCR's eyes and get them paid...but I refuse to do that because I dont want to get in trouble with MCR...so now he wants to hire another doctor to do only the visits and let our primary doc do the procedures and see if they will get paid that way...but I feel that they will still be bundled with the procedure...can someone please help me out with this...and if there is any kind of documentation of this anywhere I would really appreciate it!!!
Thanks..
Ashley Rebecca Sims, CPC-A
asims@apexcardio.com
Apex Cardiology, P.C.
327 Summar Dr.
Jackson, TN 38301
731-423-8200
"If a surgeon is admitting the patient to the nursing facility due to a condition that is not as a result of the surgery during the postoperative period of a service with the global surgical period, he/she bills for the nursing facility admission and care with a modifier “-24” and provides documentation that the service is unrelated to the surgery (e.g., return of an elderly patient to the nursing facility in which he/she has resided for five years following discharge from the hospital for cholecystectomy)."
"The Medicare physician fee schedule payment for surgical procedures includes all the services and visits that are part of the global surgery payment including when such surgical procedures may be fragmented. Subsequent Hospital Care visits (CPT codes 99231 – 99233) are not separately payable when included in the global surgery payment. The Hospital Discharge Day Management Service (CPT code 99238 or 99239) is a face-to-face evaluation and management (E/M) service with the patient and his/her attending physician. Physicians shall use the Observation or Inpatient Care Services (Including Admission and Discharge Services) using a code from CPT code range 99234 – 99236 for a hospital admission and discharge occurring on the same calendar date and when specific Medicare criteria, identified in §30.6.9.1, are met. The American Medical Association Current Procedural Terminology (CPT) codes 99238 and 99239 shall be paid only when they are performed face-to-face with the patient.
Other physicians who manage the patient's care (concurrent care) in addition to an attending physician, and who are not acting on behalf of the attending physician shall use the Subsequent Hospital Care codes from CPT code range CPT 99231 – 99233 for a final visit with the patient. Medicare includes payment for general paperwork through the pre-and post-service work of E/M services. The physician who personally performs a patient pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service using CPT code 99238 or 99239. The date of death pronouncement shall reflect the calendar date of actual death pronouncement even if the paperwork is delayed to a subsequent calendar date."
http://www.cms.gov/Transmittals/downloads/R1460CP.pdf
CMS is
super-picky about concurrent care - the second doctor would have to be managing a completely different problem, and they'd have to be a different specialty for CMS to pay them. Basically, the only way around it, would be for one doctor to bill the surgery with modifier(s) 54 (and maybe 56), and the other to bill the follow-up's with modifier 55. That wouldn't make a tremendous difference, either, since CMS would just allocate a percentage of the same RVU to each doctor. The reason there's a global period, is because they give the doctor a higher RVU, to include payment for pre-op and post-op care. (In other words, he's already been paid for it, as far as they're concerned.) I wouldn't recommend trying to cheat the system, particularly with CMS. That's playing with fire.
