Orthopedic Coding Alert

Question: Where do your coding experts find the information on H&P (history and physical) during global periods? My question is regarding Medicares global package rule. I cannot find evidence specific to H&P being a part of global no matter where it falls into the global package.

Michelle Jones
Raleigh Orthopedic, Raleigh, N.C.

Answer: The issue of postoperative H&P is one, like many, that is a result of reading rulings from several areas of the Medicare manual. First, the Nov. 2, 1991, Federal Register, which defined the global surgical package originally, discusses the billing of preoperative services. The general context was that although the preoperative period was finally determined to be the day before and the day of the surgery, HCFA reserved the right to continually review this issue. The final wording states that Medicare will pay for all medically necessary visits after the decision for surgery is made, up to the day before the surgery.

Medically necessary is the next issue. To meet the requirements of medically necessary, you must be performing some evaluation and management service of an active and ongoing nature. When the patient is brought back only for creation of the H&P document (which is required by JCAHO [Joint Commission for Accreditation of Healthcare Organizations] for the hospital before a patient can undergo surgery), getting an informed consent (including any discussion that ensues in relation to this) and providing to the patient any prep instructions, this would be listed with diagnosis code V72.83 (preoperative examination) because that is all that is being done on that day.

The surgeon is already paid about 10 percent of his surgical fee for just this type of preoperative service. (Each surgical fee is designated to have a certain percentage appropriated for preoperative care, intra-operative work and postoperative care.) If you have specific questions about this, you should contact your local Medicare carrier and provide them with the scenario of performing a preoperative H&P only outside the 24- to 48-hour range and get their ruling before billing for this service.