Contracted Providers and Global Packages

Messages
8
Location
Greenville, NC
Best answers
0
Please help.
- A hospital enters a contract with a surgeon utilizing a professional service agreement.
- The contracted surgeon performs a surgery and does all their own billing with their tax id and NPI.
- The hospitals physician group, of the same specialty, treats the patient in critical care during the global period.
- Can the hospitals physician group bill the critical care codes utilizing their own tax id and NPI?

Any resources to support yes or no?
 
Last edited:

csperoni

Expert
Messages
377
Location
Selden
Best answers
1
I'm not sure I fully understand the situation.
The contracted surgeon is not 100% employed and also has a private practice? And the surgery was done and billed as part of his private practice? Was there a transfer of care? Why are other physicians of the same specialty caring for the patient and not the operating surgeon?
Obviously, if the critical care is unrelated to the surgery, then any provider who rendered service may bill as it is not part of the global package.
If the critical care is related to the surgery, I would need some further explanation on my questions above, but it would seem the operating surgeon is not providing postop care, so should bill only the surgery itself and the hospital group bill the postop care.
There are services outside the global which may apply as well.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf Section 40.1 part B (page 91-92)
If there was a transfer of care as it seems the operating physician is not providing the global postoperative care, review 40.2.3
Hope some of this helps, and if you supply some further explanation, it may become clearer what the answer should be.
 
Messages
8
Location
Greenville, NC
Best answers
0
The hospital does not have enough surgeons to meet patient need. The hospital contracts with outside providers to fill the void. The contractors bill their own revenue, if the fall short the hospital pays them additional funds per value market standards. The hospitals physician group sometimes need to do inpatient follow up or critical care to those patients within the global. In one hand we're cautious about billing since there is a financial link, on the other hand, the entire global package is being paid to the contractors group, not us.
 

csperoni

Expert
Messages
377
Location
Selden
Best answers
1
I do not think this is billable. It seems from a purely coding standpoint, the surgical billing should really be split since the operating surgeon is not actually performing the entire global package. Since that is not taking place, I would consider this like solo practice ob/gyns who have reciprocal agreements with other ob/gyn practices. They each agree to provide services to the other's patients when they are on call, but since the service they are providing would be part of the global, the covering doc does not bill for those services since they SHOULD be global. I will assume whatever contract the hospital and the outside surgeons have was carefully reviewed by attorneys who know the legal implications clearly more than I would as a coder.
Again, if any services are being provided that are specified as outside the global, then by all means, bill for those.
I am certainly open to other opinions if anyone else wants to weigh in here.
 
Top