Wiki charging in the post op period

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THELMAP

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Just wanted to see if anyone had any guidance for billing an E&M in the post op period for diagnosis codes such as anemia, weight, smoking, kidney dysfunction, vitamin D deficiency etc. We have a new provider for an ORTHOPEDIC practice
that is wanting to bill E&M in the post op period for other issues that I feel are somewhat related to the surgeries he is performing. When I question him the answer I get is he is ordering labs and interpreting them and that it is a common issue for general musculoskeletal health maintenance to prevent osteopenia/osteoporosis and fractures and it can also affect the quality of the bone for surgical procedures and future bone health for subsequent injury prevention and bone surgery. I guess maybe I am looking at this ethically and thinking that it should be inclusive of the surgery itself and not separately billable. Even after charging the first post op then all the following visits are getting charged also. because now he is treating for the Vitamin D level. I am really confused at this point so any pointers would be very much appreciated. He does make a small section in the assessment and plan that he is billing for this MDM in the post op due to whatever the reasoning is. Thanks for any input.
 
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This is a bit convoluted to try and give an answer to. It would always come down to the specific documentation of the encounter being performed during a post-op period. You would have to take each encounter and scrutinize it. Why would an orthopedic surgeon be managing the patient's anemia, weight, smoking, and kidney dysfunction? I get that those all impact bone healing and surgical procedures but I have not seen where an ortho surgeon would take on this management. It even makes sense that they might order and review labs for these things. The patient is managed by their PCP. Unless, the provider is working in an orthopedic practice but they are managing patients with osteoporosis or something (endocrinology?).

The question is, what procedure(s) is the patient in global for. Was the follow up office visit directly related to those procedures during the global? I have seen where there could be E/M during the global for multi-trauma patients possibly where they had lots of anatomical areas involved but not all had surgical procedures. Also, in large clinics, patients might be in a global for a wrist fracture but then they are seen by another MD for a foot as an example.

"● Underlying condition treatment or an added treatment course that’s not part of normal surgery recovery.● Diagnostic tests and procedures, including diagnostic radiological procedures."
This is a good question: Would that be part of normal surgery recovery?
I would say you would not expect to see E/M during the global every time the patient comes in for follow up of that surgery. Definitely not on every patient. You could look at that too, is this happening on every patient all the time? Probably not supported.
 
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That is my question. The patient is coming in for follow up (global orthopedic surgery) and the physician is checking other issues from their pre-op labs such as Vitamin D level, kidney dysfunction, anemia, in the follow up
visits and wanting to bill an E&M for this. I am thinking that maybe the first visit post op to go over this and then their primary care doctor take over the care would be supported. And not happening on every patient every time but enough for me to start digging and trying to research the issue. The terminology used in the chart: example is that (I am billing for the MDM associated with the patient's vitamin D deficiency. This problem is unrelated to the surgery that is in the global postop period. Managing this issue will optimize the patient's orthopedic treatment as well as general medical health). That is one example of the documentation for this. Does
any one else have physicians that are doing this?
 
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THELMAP said:
That is my question. The patient is coming in for follow up (global orthopedic surgery) and the physician is checking other issues from their pre-op labs such as Vitamin D level, kidney dysfunction, anemia, in the follow up
visits and wanting to bill an E&M for this. I am thinking that maybe the first visit post op to go over this and then their primary care doctor take over the care would be supported. And not happening on every patient every time but enough for me to start digging and trying to research the issue. The terminology used in the chart: example is that (I am billing for the MDM associated with the patient's vitamin D deficiency. This problem is unrelated to the surgery that is in the global postop period. Managing this issue will optimize the patient's orthopedic treatment as well as general medical health). That is one example of the documentation for this. Does
any one else have physicians that are doing this?
Click to expand...
It's a fine line I think. If you were to cross out anything in the note related to the global, what would be left? Would it be enough for an E/M stand alone? Try looking at it that way. Does it support a modifier 24? Are they actually managing it? It really is going to depend on the particulars of each visit and the patient. I don't know that anyone can give you a firm yes/no on every one for this. It is going to depend on the patient. Usually, they recommend vitamin D for fracture healing so to me, that would be related. Would the provider have otherwise managed this problem or found it? Seems to me it is still related to the global. Could it be viewed as "Underlying condition treatment or an added treatment course that’s not part of normal surgery recovery"?

In nine years of working in an orthopedic practice with over 100 providers, I have never seen this billed for during the global by the surgeon. They tell the patient(s) to possibly take vitamin D and other information for general health support but no E/M is billed. They refer the patient back to their PCP or another specialist for management of things like this. *Edited to add: What I have seen is in a big group, where there is an endocrinologist/metabolic doc/bone doc/osteoporosis doc, the ortho surgeon refers the patient to that provider for management. I think it also depends on the geographic region and type of practice. If you are talking possibly a very small practice, rural health area, etc. it is much more likely a general ortho would possibly do things like this. In a big city, probably not so much. Is it a big group or small/solo practice?

If they are specifically stating it is unrelated and they want it billed, there is not much you can do if the provider insists. It is up to them ultimately. You can advise and guide. We are not providers though...

Also, if it is a brand new provider, I have seen where they bring bad habits from other practices or if new grads, possibly need education from a coding and documentation standpoint. Is there a peer provider in the group that is a coding advocate?
 
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I really appreciate your response. He is a new provider here and although he has been given guidance it will ultimately be up to him as the provider and I have let him know this. I have been in this orthopedic practice
for 30+years and have never had a physician wanting to bill in the post op for these issues so that is why I was looking for other guidance. He is stating that he is managing the issues because it relates to the orthopedic
health of the patient. Once again thanks for the input.
 
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THELMAP said:
I really appreciate your response. He is a new provider here and although he has been given guidance it will ultimately be up to him as the provider and I have let him know this. I have been in this orthopedic practice
for 30+years and have never had a physician wanting to bill in the post op for these issues so that is why I was looking for other guidance. He is stating that he is managing the issues because it relates to the orthopedic
health of the patient. Once again thanks for the input.
Click to expand...
Good luck! I suppose once the provider starts showing up as an outlier for modifier 24 you may see change. And, if/when audit request come in depending on the volume.
 
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