Cancer Surveillance during post op period for resection of tumor

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One of our providers who is an Orthopedic Oncologist removed a sarcoma of the left shoulder CPT 23078 in September. He has continued to bill regular office visit codes rather than post op visits because, in his opinion, he is doing "cancer surveillance" and therefore he states that these visits would meet the criteria of a "separately identifiable E&M service during a post op period". He has examined the same shoulder and ordered and reviewed MRI's and CT scans of the same shoulder/chest to watch for metastatic lesions. There are no complications from the surgery and there are no other areas of cancerous concern. Are those E&M visits billable? Is this an acceptable practice?
 

csperoni

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It is likely appropriate to bill if (as noted above) it is treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery.
Great reference - CMS Global Surgery booklet https://www.cms.gov/outreach-and-ed...oducts/downloads/globallsurgery-icn907166.pdf
What services are not included in the global surgery payment?
The following services are not included in the global surgical payment. These services may be billed and paid for separately:
• Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier “-57” (Decision for Surgery). This visit may be billed separately only for major surgical procedures.
• Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record.
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery
• Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery
• Diagnostic tests and procedures, including diagnostic radiological procedures
• Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications
• Treatment for post-operative complications requiring a return trip to the Operating Room (OR).
• If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.
• Immunosuppressive therapy for organ transplants
• Critical care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician
 
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These can be billed if they are for the underlying condition and not for post operative surgical care.
This is where the question lies. Is an MRI of the area where the sarcoma was removed post operative care OR treatment for the underlying condition? The patient does not have cancer anywhere else and the provider is re-checking the surgical area.
This feels very similar to when our Orthopedic providers surgically correct a fracture, then perform an x-ray at the follow up visit to ensure alignment has been maintained. Its simply a re-check of the same area of the body and the same condition. In the fracture scenario we would never bill for that office visit simply because the provider took an x-ray.
 
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It is likely appropriate to bill if (as noted above) it is treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery.
Great reference - CMS Global Surgery booklet https://www.cms.gov/outreach-and-ed...oducts/downloads/globallsurgery-icn907166.pdf
What services are not included in the global surgery payment?
The following services are not included in the global surgical payment. These services may be billed and paid for separately:
• Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier “-57” (Decision for Surgery). This visit may be billed separately only for major surgical procedures.
• Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record.
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery
• Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery
• Diagnostic tests and procedures, including diagnostic radiological procedures
• Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications
• Treatment for post-operative complications requiring a return trip to the Operating Room (OR).
• If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.
• Immunosuppressive therapy for organ transplants
• Critical care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician
This is where the question lies. Is an MRI of the area where the sarcoma was removed post operative care OR treatment for the underlying condition? The patient does not have cancer anywhere else and the provider is re-checking the surgical area.
This feels very similar to when our Orthopedic providers surgically correct a fracture, then perform an x-ray at the follow up visit to ensure alignment has been maintained. Its simply a re-check of the same area of the body and the same condition. In the fracture scenario we would never bill for that office visit simply because the provider took an x-ray.
 

thomas7331

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This is where the question lies. Is an MRI of the area where the sarcoma was removed post operative care OR treatment for the underlying condition? The patient does not have cancer anywhere else and the provider is re-checking the surgical area.
This feels very similar to when our Orthopedic providers surgically correct a fracture, then perform an x-ray at the follow up visit to ensure alignment has been maintained. Its simply a re-check of the same area of the body and the same condition. In the fracture scenario we would never bill for that office visit simply because the provider took an x-ray.
I see where you're coming from here, but think you're comparing apples and oranges. A surgery to repair a fracture does include checking alignment as a routine part of the normal post-operative care for that type of surgery, so the costs and work involved would be figured into the reimbursement for that type of procedure. A surgery for a lesion removal, on the other hand, is a very different procedure and the normal post-operative course of treatment would just involve evaluating the patient and the site to ensure that it is healing appropriately. The work involved in surveillance of cancer is not part of post-operative care for lesion removals. If, for example, this was a benign lesion such as a lipoma, there would be no cancer surveillance involved in the post-operative course of treatment, yet the reimbursement for the procedure would be the same. I tend to agree that since this is additional treatment of an underlying disease process that this could be considered a separately billable service.
 
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I see where you're coming from here, but think you're comparing apples and oranges. A surgery to repair a fracture does include checking alignment as a routine part of the normal post-operative care for that type of surgery, so the costs and work involved would be figured into the reimbursement for that type of procedure. A surgery for a lesion removal, on the other hand, is a very different procedure and the normal post-operative course of treatment would just involve evaluating the patient and the site to ensure that it is healing appropriately. The work involved in surveillance of cancer is not part of post-operative care for lesion removals. If, for example, this was a benign lesion such as a lipoma, there would be no cancer surveillance involved in the post-operative course of treatment, yet the reimbursement for the procedure would be the same. I tend to agree that since this is additional treatment of an underlying disease process that this could be considered a separately billable service.
That makes perfect sense. Thank you so much! Would you be able to point me to any official sources that we could use to support this position? It has become a topic of debate in our office.
 
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