Wiki Medicare Coding Question (really more Billing than anything)

[jveronick]

We are having an issue with a patient. He is stating that he has been told by Medicare that his dad can have a second surgery only 60 days after the first procedure (same body part - opposite side).

However, my very experienced biller (30 years) is having difficulty making him understand the concept of the 90-day global period and the fact that if we do surgery prior to that time on a second body part, we most likely won't get paid for the surgery.

So, if a Medicare patient has a surgical procedure with a 90-day global period, when is the earliest that patient can have another procedure by the same surgeon? EG: Patient has a LEFT total knee on 1/1/17. Is the EARLIEST he can have the RIGHT total knee at any date after April 3rd (92 days total as listed in the CMS global period)? Is my biller missing something?

Any references you can point us to would be helpful as the patient states he has two sources that are telling him 60 days - one at the national office and one at the local office. HELP!

Julie V.
TJRC

 

[CodingKing]

There are modifiers for unrelated procedure in the Post-op period.

[FONT=&quot]79 - [/FONT][FONT=&quot]Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period: [/FONT]

 

[thomas7331]

It sounds to me like there is a misunderstanding here - the 90 day global period only defines the services that are included in a surgical package payment for the procedure - it has nothing to do with what procedures may or may not be covered. Global packages are a payment methodology, not a benefit restriction or a mandate on how to provide care, and I seriously doubt that Medicare would tell a patient that they could not have a necessary procedure done because they are in a global period. And in any case, if the procedure is on an unrelated body part, it is not part of the global package and the biller is giving wrong information by saying that you probably wouldn't be paid because of this - as the previous post states, a modifier 79 would resolve that issue.

The mention of a 60 day period makes me think that this is one of two things - when a patient is admitted to a hospital, they begin a 60-day benefit period under Part A and any readmission would be included in that same benefit period and there would not be a new deductible; after 60 days, the benefit resets again - they could be referring to this. The other possibility is that if the facility and/or your physician are participating in the new bundled payment or comprehensive care payment models (BPCI or CJR), they could be telling the patient that they are still in a 60-day period for that program. I'm not very familiar with how those models work, but there may be regulations about getting a second joint replacement during that same period.

Either way, I think both the patient and the biller may be misunderstanding what Medicare is telling them, and I'd recommend arranging a 3-way call with Medicare, the patient and someone from your office to get clarification on exactly what information is being communicated to this patient.