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EK226

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Hello ~

I have a question regarding the use of 99233. I am following up on a denial received for 99233 stating that it was part of the global timeframe.

After review, the patient had a Laminectomy procedure on 7/27/09 (provider billed w/ 63047 which does have a 90 day global timeframe) The physician who performed the procedure has been paid, but apparently when the patient was in the hospital they had to have a consultation by a pulmonary specialist on 7/28, and 7/30/09. The pulmonary specialist is billing with 99233. Both of these dates of service were denied stating that they were within the global timeframe.

Is there any way to get this pulmonary physician paid? I can't seem to find an appropriate modifier for 99233. I didn't think 25 would be appropriate to use since it states "same physician, and same day of procedure"

Any suggestions?
Thanks,
 
The pulmonary doctor is using the same dx that the other doctor is using, and yes they are both in different tax ID's, two totally different practices. I read the description for mod 24 and this also says "same physician" I thought this modifier could only be used if it's the same physician?
 
This sounds like an error on the insurances part. The global period only applies to the physician (or same group/same specialty partner) that did the procedure. Unless your provider is doing all the post op care.

Laura, CPC, CEMC
 
I'm not sure if the pulmonary physician or the orthopedic physician will be doing all the follow up care. It's for a worker's compensation claim, and we just receive the bills as they come in from all of the providers who are treating the patient. The services billed by the pulmonary physician were actually denied by the Bureau of Worker's Comp stating that the services were rendered during the global timeframe. I feel that the services billed by the pulmonary physician are appropriate and should not be denied as part of global since that physician is not the one who performed the surgery...
 
Lets see this from the work comp side, how is the patient's pulmonary issues related to the work comp case. If it is a surgical complication what dx codes are you submitting.
Actually can you list all the codes that were submitted on the denied claims?
 
When I called the pulmonary physician's office I asked them if the doctor was treating any complications, and was adivsed that the doctor was providing regular services in the surgical ICU. I'm not quite sure what exactly would be "regular services". I have yet to see the doctor's notes from these dates of service, I hope that once I see the notes it might provide a more clear picture. I had to request the notes from medical records at the hospital so I'm still waiting....

As for as the work related conditions the patient doesn't have any pulmonary conditions in the worker's comp claim...all of the allowed conditions are for back contusion, lumbar sprain, lumbar degenerative disc, & spinal stenosis
 
So if the Pulmonary issue is not a part of the work comp claim, then you cannot bill those services to work comp. You will need to send a separate claim to the medical insurance for the non work comp issues. If the pulmonary is a surgical complication then you will need authorization from the work comp to start a new claim for the pulmonary.
 
I have the notes now in front of me, and it appears that the patient experienced respiratory failure while in the hospital, and had to be intubated. So it seems as though there were complications from the surgery, and since these were complications, there may not be an allowance for these conditions in the worker's comp claim? I'll have to do some more digging on this, but I just wanted to let you know what I found out.

Thanks for your help, I appreciate it!
 
If the patient experienced complications from the surgery they should be covered by workers comp. However, the pulmonary doctor should be codoing complication codes (since I don't have the notes I can't say which but for example 518.5-pulmonary insufficiency following trauma and surgery, or 997.39-other respiratory complication) primary with the work comp codes secondary (unless it's Federal Work comp). I work for a cardiology practice and we have been paid by worker's comp for surgical complications.

Doreen, CPC
 
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