Pediatric Coding Alert

For proper reimbursement, pediatricians administering post-op care should use a different diagnosis code from the surgeons. Its a fairly common dilemma for pediatricians: A child goes to a surgeon for a procedure, but during the postoperative period comes to the primary-care provider for another problem, which may or may not be related to the surgery.

Often, the insurance company assumes that the new problem is related to the surgery, and it wont pay the primary-care pediatrician for his or her encounter because the encounter takes place during the 90- or 10-day global period. The payment for the surgery is supposed to cover all related care by the same physician during that global period.

Global Period Applies to Surgeon Only

The global fee covers the operating surgeon (in the absence of modifiers -54 [surgical care only] and -55 [postoperative management only]) even if the diagnosis for the postoperative visit is related. If the diagnosis for the postoperative visit is unrelated, insurance companies rarely have a problem paying, and no modifiers are necessary.

A typical scenario follows:

Scenario #1: A urologist performs a circumcision (V50.2 ). Then, the site starts looking infected to the parent. The parent brings the child to the primary-care pediatrician to have it checked because the urologist is two hours away. The insurance company tells the pediatrician that the visit was covered by the global fee for the surgery, and therefore the pediatrician will not be paid.

According to Dari Bonner, CPC, CPC-H, CCS-P, president and owner of Xact Coding and Reimbursement Consulting in Port St. Lucie, Fla., the insurance company should reimburse the pediatrician. It cant be in the global period for the surgery if its a different physician. The global period only applies to the surgeon, says Bonner. This is true regardless of whether the problem the child consulted the pediatrician for is related to the surgery or not. In the above scenario, what looked like an infection could have been diaper rash (691.0), or it could have been an infection of the wound. In either case, the pediatrician should be paid for treating the condition. And the insurance company should, in Bonners words, be corrected.

Bonner notes that her comments are based on reimbursement guidelines, not coding guidelines. CPT tells you that the urologist should be paid for the surgical procedure, and that if the urologist doesnt do the post-op care, the pediatrician should be paid for the post-op care, she says. But in practice, this never happens, because its impossible to track. Technically, co-management would refer to the primary-care pediatrician, in this case, signing up ahead of time to provide all postoperative care on the patient. That is not quite what [...]