Orthopedic Coding Alert

Question: Patients are seen three to four days in the office prior to ACL reconstruction. The visits consist of the following:

brief history

repeat physical exam complete knee and general

review of surgery risks, benefits, and
complications

discussion of surgical risks

discussion of dictation of history and physical

Can we bill for this office visit at level 4 or is it included as part of the global fee?

Jeffrey Greenspoon, MD
Space Coast Orthopedic Center
Merritt Island, FL

Answer: Typically, the global package is the day before the surgery and 90 days afterward. However, the history and physical (H&P) are included in the global fee schedule and should not be charged separately no matter when its performed. Medicare wont check for violating the global fee period in a prepayment audit.

However, auditors say if they see evidence of your practice constantly bringing patients in prior to that 48-hour period outside the global period in order to circumvent the global package, they have the right to examine the records of each physician and figure overpayments accordingly. Your records are subject to being checked as far back as seven years ago.
Therefore, whether you can appropriately charge for this E/M service depends on medical necessity. Ask yourself: Is there a new medical reason or change in the patients condition to warrant bringing the patient back into the office preoperatively after the decision for surgery has been made? If the answer is yes, then an E/M code is appropriate. If its no, then you run the risk of a post-payment review.