Correct E & M for PO hospital Readmission

Bklynkr

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We have a patient that had knee replacement outside of our facility. She was seen for a PO issue a few months ago in our hospital. She is being re-admitted again for the same issue- still in the PO period. Do we use 99024?

Thanks.
 
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What was billed the last admit to your facility? Is the post op issue a complication of the surgery?
 

Bklynkr

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Correct E and M for PO hospital readmission.

Morning! yes, it was due to a wound complication- non healing. I'm used to office billing. but for hospital 99024 is still used for readmission, when we saw the patient prior also for po wound care??
 
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Couple more questions...

On the first admit for the complication, did the patient get actually admitted to inpatient?
If so, how was she there for a period of time, not just a day or two?
If the patient was admitted to inpatient, were any procedures performed?
Besides the admit code for the first due to complications, were there any other codes billed besides the daily subsequent care and discharge codes? i.e., Did she have to return to the OR for treatment?
When she was discharged, was the complication basically "taken care of"?


On this second visit, was she admitted to inpatient?
What were the circumstances, generally speaking, on why the first admit for treatment didn't work?
If she was admitted to inpatient, were any procedures performed? If so, did that require a return to the OR?

The billing for this basically revolves around the particulars...
 

Bklynkr

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On first admit patient had wound issues- non healing from the outside procedure. an I and D was done. Patient stayed a few days. Patient has been non/compliant or unable to care for the wounds from home. On this second admit, patient having same issues. Also, stayed for at least (2) days. Would it be easier to know under what conditions the 99024 would be used. Is it only when patient is admitted, has surgery and then seen under that same admit? Appreciate your help.
 
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Okay, there's a couple of things going on here. Sorry in advance for the long reply.

First, regarding global periods in general, here's what's included in the surgical package and is NOT payable:
• Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;
• Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a surgical procedure;
Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room;
• Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery;
• Postsurgical Pain Management - By the surgeon;
• Supplies - Except for those identified as exclusions; and
• Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes

Here's what is NOT included in the surgical package:
• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure;
Services of other physicians 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 during the postoperative period which are not re-operations or treatment for complications. (A new postoperative period begins with the subsequent procedure.) This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. Examples of this are procedures to diagnose and treat
epilepsy (codes 61533, 61534-61536, 61539, 61541, and 61543) which may be performed in succession within 90 days of each other;
Treatment for postoperative complications which requires a return trip to the operating room (OR). An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy
suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR);
• If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;
• For certain services performed in a physician’s office, separate payment can no longer be made for a surgical tray (code A4550). This code is now a Status B and is no longer a separately payable service on or after January 1, 2002. However, splints and casting supplies are payable separately under the reasonable charge payment methodology;
• Immunosuppressive therapy for organ transplants; and
• Critical care services (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

So basically all of the care that's been provided for the post op complications is considered part of the global package and is not separately payable. If the complication required a return to the OR, then it could be payable with the appropriate modifier.

Now it gets tricky... so here's how I interpret it;
Those guidelines apply to the surgeon who did the procedure, which is NOT the case here. The deciding factor appears to be whether or not a transfer of care was agreed to. If there was an agreement, then you could not bill for any services.

If there was no agreement for transfer of care, then the charges from your facility (being a separate hospital and a separate provider), would not be considered part of the global package, for the first visit at least. In the case where there was no agreement to transfer care, the provider from the first visit should be able to bill for their services; the admit, the procedure, etc.

The transfer of care is essentially THE problem in this case, IMO. If there was no agreement of transfer of care, the first visit should be payable, I believe. I could be wrong here, but I would also tend to believe that the second visit could be payable because again, it's a different provider (not the surgeon). You may run into a global period with the first visit (I&D), if there is one. The part I'm stuck at is, at what point does the "separate provider" rule not apply, if ever? By providing the care now, is that considered taking over via "assumed care"? I have no answers on that one.
 

Bklynkr

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Appreciate the information. Will review what you have sent- seems there can be a few "grey" areas. Have a nice weekend.
 
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