Decision for surgery

nlbarnes

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A co-worker just informed me that if a surgeon makes a decision for surgery during an office a month (for example) prior to the surgery, that any office visits between then and the surgery is not billable. I don't bill an E/M the day before just for clarification, but I've never heard of this or interpreted the Global Surgery Fact Sheet as such. In all my years, I've never not billed any visits in between but I haven't had many that I can think of.

Thoughts, clarification???

Thanks
 

mhstrauss

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A co-worker just informed me that if a surgeon makes a decision for surgery during an office a month (for example) prior to the surgery, that any office visits between then and the surgery is not billable. I don't bill an E/M the day before just for clarification, but I've never heard of this or interpreted the Global Surgery Fact Sheet as such. In all my years, I've never not billed any visits in between but I haven't had many that I can think of.

Thoughts, clarification???

Thanks

IMO, it depends on what the reason for those visits is. I think in a typical scenario, the surgery is decided on at a particular visit, the surgery is scheduled for, like in your example, a month away, and the only reason a patient needs to come back in the meantime is to finalize consents, etc. But, if the visits between the decision for surgery DOS and the surgery are actually medically necessary, ie. changes in patients condition, maybe try one more treatment before going through with the surgery, things like that, then the visit should be billed. I also do not interpret the Fact Sheet that way.

HTH some!
 

nlbarnes

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Decision for Surgery

Thank you Meagan. My prayers for your officers, family, friends, city and all affected by this tragedy.

Take care...
 
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Good old Medicare and their mountains of rules says that any pre-operative visits after the decision for surgery has been made and prior to the surgery itself are considered part of the global package. Once the decision was made, apparently that sealed the deal. So depending on the situation, I'd find out what these visits were for and if they had anything to do with the surgery, then I guess they're stuck in the global period. This would include visits for additional pre-op workup according to the guidelines. It seems odd that a decision would be made AND THEN subsequent visits would occur "just to make sure." It makes me wonder if the 57 actually did belong on that particular DOS.

If it were me, I think the avenue I'd go down is to read all the notes for the decision DOS and the visits in-between and figure out if the decision was rescinded and then decided again later (closer to the actual surgery date). If that's the case, I'd get the original claim billed with the 57 reprocessed to reflect no modifiers and support that with documentation to show the decision was made but then rescinded upon or that the decision made that day was dependent upon such and such testing (which would explain the visits in the meantime) so that DOS no longer was a decision date. I'd probably try the appeal route and include proof that the decision was finalized "for sure" at a later date and make sure THAT claim was billed with the 57, subsequently asking for a reprocessing of the original DOS with the removal of the 57. I'd assume that you'd have to get the appeal done and approved before you could submit the new claim with the 57, IF that was the case.

If the surgery was minor and had a 10 day global period, but a month passed, then I'd still appeal for reprocessing of the original claim, asking to remove the 57, because it would look kind of shady in an audit... like a way to squeeze in some extra visits to get paid before the procedure kind of situation. I don't think I'd let that just play out, mostly just to make sure I cover myself if anything were to come of it. Not saying that's the case here, but better to be proactive than to get a "come to the principal's office" letter from the payer.
 
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mhstrauss

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Good old Medicare and their mountains of rules says that any pre-operative visits after the decision for surgery has been made and prior to the surgery itself are considered part of the global package. Once the decision was made, apparently that sealed the deal. So depending on the situation, I'd find out what these visits were for and if they had anything to do with the surgery, then I guess they're stuck in the global period. This would include visits for additional pre-op workup according to the guidelines. It seems odd that a decision would be made AND THEN subsequent visits would occur "just to make sure." It makes me wonder if the 57 actually did belong on that particular DOS.

If it were me, I think the avenue I'd go down is to read all the notes for the decision DOS and the visits in-between and figure out if the decision was rescinded and then decided again later (closer to the actual surgery date). If that's the case, I'd get the original claim billed with the 57 reprocessed to reflect no modifiers and support that with documentation to show the decision was made but then rescinded upon or that the decision made that day was dependent upon such and such testing (which would explain the visits in the meantime) so that DOS no longer was a decision date. I'd probably try the appeal route and include proof that the decision was finalized "for sure" at a later date and make sure THAT claim was billed with the 27, subsequently asking for a reprocessing of the original DOS with the removal of the 27. I'd assume that you'd have to get the appeal done and approved before you could submit the new claim with the 57, IF that was the case.

If the surgery was minor and had a 10 day global period, but a month passed, then I'd still appeal for reprocessing of the original claim, asking to remove the 27, because it would look kind of shady in an audit... like a way to squeeze in some extra visits to get paid before the procedure kind of situation. I don't think I'd let that just play out, mostly just to make sure I cover myself if anything were to come of it. Not saying that's the case here, but better to be proactive than to get a "come to the principal's office" letter from the payer.



An E/M service a month prior to surgery should not have modifier 57, I don't believe that is what the OP was asking about.
Also, modifier 27 is not one that can be used on E/M services...i'm not sure what you're referring to.
 
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An E/M service a month prior to surgery should not have modifier 57, I don't believe that is what the OP was asking about.
Also, modifier 27 is not one that can be used on E/M services...i'm not sure what you're referring to.

Sorry, mis-typed. I'll correct it.
 
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