Orthopedic Coding Alert

Orthopedic surgeons and their staff who work with residents in a teaching hospital or a teaching setting need to be mindful of a key requirement when it comes to coding and billing. The physical presence of the teaching physician is critical to both maximum reimbursement and legal reporting of physician supervision per the Health Care Financing Administrations (HCFA) requirements for Medicare patients.

HCFA requirements for both emergency department (ED) and regular admits in a teaching setting whether a hospital or a private practice hinge on who is performing the service to the Medicare patient and the creation of the appropriate documentation for the service.

Missed Opportunities to Code for Care

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., with experience coding in teaching hospitals, says, The biggest problem I see over and over is that the teaching physicians dont always make it to the ED. From a coding and billing perspective, they cannot bill for certain services because the services are performed by a resident and not in the presence of a teaching physician.

Callaway-Stradley offers the example of fracture care. If a resident evaluates the patient and provides fracture care (27750, closed treatment of tibial shaft fracture [with or without fibular fracture]; without manipulation) without the appropriate participation and supervision of a teaching physician, no bill can be submitted to Medicare. Nor can a bill be submitted for 99281-99285 (emergency department visit for the evaluation and management of a patient). The hospital could bill for use of the facility and for any supplies not included with 27750, but there is no way legally the facility can bill for a doctors services when none is present.

Callaway-Stradley says that as a result of this initial lack of supervision in the ED, another problem often occurs. When the patient returns to the clinic for follow-up care, the encounter form is marked with 99024 to indicate that a postoperative visit has occurred that is included in the global package for the fracture care. But because no global package has been billed, the visit is billed using regular evaluation and management (E/M) codes 99201-99205 (office or other outpatient visit for the evaluation and management of a new patient). As a result of this confusing situation, some patients could receive a major portion of their fracture care for free because of the lack of adequate supervision in the ED and a lack of communication at the clinic level. This can represent a significant loss in revenue over time. This still boils down to the problem of having the teaching physician actually be in attendance in the ED, adds Callaway-Stradley.

In the case of the follow-up care, Blair Filler, MD, FACS, director of medical education at Los Angeles Orthopedic Hospital in California, concurs that when the patient returns to the hospital (or other teaching setting) for follow-up care, an E/M charge for a new patient (99201-99205) is appropriate. But this is only if the patient is seen by a staff physician upon return, says Filler, and only if that doctor has not treated this same patient within the last three years. Otherwise, the established patient codes 99212-99215 codes should be used.

Degree of Presence Needed for Follow-up Care

If a teaching physician is present for the initial treatment of the fractured tibia (27750), further distinctions arise with regard to the follow-up care. Filler points out that for global period follow-up visits after a staff physician-performed procedure, the staff doctor must see the patient during the critical or key follow-up visits. The critical or key visits are defined by the staff doctor based on the service performed, identified as such and signed off on.

Sheri Benton, CPC, coding and reimbursement specialist in the department of orthopedics at the Cleveland Clinic Foundation in Ohio, points out that from a billing perspective, follow-up would be included in the global period for the 27750 and therefore not separately billable. The resident can conduct the follow-up care, says Benton, but the teaching physician should be present, depending on the nature of the original complaint. Benton says that there is no obligation for the teaching physician to examine the patient during follow-up and, in fact, treating a patient for follow-up care is an important element of the residents learning process.

Filler adds that because the reimbursement of all procedures with a global service period include post-operative care, proper documentation must indicate that the teaching physician was involved and present during the key portions of the postoperative visits. What is key is left up to the teaching physician so that his or her attendance is not required at all visits, says Filler.

Physical Presence Is a HCFA Requirement

The physical presence of the teaching physician in the ED or operating room (OR) setting is not only essential to optimal reimbursement, it is a requirement mandated by HCFA. Although the HCFA rules apply to Medicare and not to commercial carriers, facility compliance plans may require that these requirements be applied across the board.

Benton says that for surgical cases, such as 27758 (open treatment of tibial shaft fracture [with or without fibular fracture] with plate/screws, with or without cerclage), the teaching physician should be there for opening and closing, and the critical portions of the procedure. Filler points out that, again, this depends on the complexity of the surgery, and it is the teaching physicians responsibility to determine whether he or she needs to be present based on that complexity. For all arthroscopic/endoscopic procedures, either diagnostic or surgical, the physician needs to be present for the entire viewing. To meet the HCFA requirement, says Benton, both to adhere to the law and to bill for surgeries, documentation must prove that the teaching physician was there for the critical portion of surgery and the entirety of the endoscopy/arthroscopy.

Callaway-Stradley points out that years ago, all the teaching physicians had to do was sign off that they had seen the patient and agreed with the diagnosis and treatment. Now documentation must prove that they are actively participating in the patients care, she explains, and see the patient face-to-face.

Teaching hospitals have been under the gun on this issue for some time, Callaway-Stradley says. She mentions many of the ongoing audits of teaching hospitals, particularly ones performed in recent years. The hospitals often billed for services in the name of the teaching physician when he was not physically present in the hospital, she says. The current documentation requirements hopefully have eliminated this inappropriate billing, but at the same time the teaching physicians should make sure they have not created holes in their communication process that allows legitimate charges to slip through.

A comprehensive explanation of HCFA requirements for teaching settings is available online at http://www.hcfa.gov/pubforms/14%5Fcar/3b15000.htm#_1_8. The Association of American Medical Colleges Web site at www.aamc.org has regularly updated information and news on issues affecting medical teaching facilities nationwide.

Defining the Requirements For Teaching Settings The following excerpt from HCFAs Web site defines some of the requirements for teaching settings: Resident means an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting. The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary. The fact that an individual hospital does not choose to include an eligible individual in its full-time equivalency count of residents does not change that individuals status as a resident in an approved GME program. A medical student is never considered to be a resident. Any contribution of a medical student to the performance of a service or billable procedure (other than the taking of a history in the case of an E/M [evaluation and management] service) must be performed in the physical presence of a physician or jointly with a resident in a service meeting the requirements set forth below for teaching physician billing. Teaching physician means a physician (other than another resident) who involves residents in the care of his or her patients. Direct medical and surgical services mean services to individual beneficiaries that are either personally furnished by a physician or furnished by a resident under the supervision of a physician in a teaching hospital making the reasonable cost election for physician services furnished in teaching hospitals. All payments for such services are made by the fiscal intermediary for the hospital. Teaching hospital means a hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry, or podiatry. Teaching setting means any provider, hospital-based provider, or nonprovider setting in which Medicare payment for the services of residents is made by the fiscal intermediary under the direct graduate medical education payment methodology or freestanding SNF (skilled nursing facility) or HHA (home health agency) in which such payments are made on a reasonable cost basis.