Global Surgery and Copays


Lewiston, ME
Best answers
:confused: HELP!
I'm a relatively new coder in an orthopaedic practice where recently we've been having trouble with the front end collecting copayments when perhaps they shouldn't have. First of all, let me add that I'm new to coding in general. I've read and re-read the Medicare general surgery guidelines and noticed that it says "diagnostic tests and procedures, including diagnostic radiological procedures" are NOT included in the global packages. What is happening in our office is this: Whenever a patient comes in follow up and the office visit is a 99024, the check out person is telling them "you're all set" and the patient does not pay a copayment. The question arises when they also have an x-ray or an injection or a cast and we bill their insurance for that portion. I was under the impression that in those cases, the patient does have a copay. Many of the girls out front are telling me that if it is in follow up, there is no copayment charge...period...even if we are billing for x-rays, etc. As I'm new at this, I'm not sure where to turn for definitive answers. I'd really appreciate some insight and source documents I can keep here in the office should the problem arise again. Thanks in advance for any info!
On the patient card when it says that they have a "$15.00" co-pay that is for the office visit. However, some insurance plans do require co-pays for diagnostic testing/procedures. This would vary from plan to plan and you would have to call each person's insurance to know for sure if a co-pay is due for this diagnostic testing/procedure that is being done. I hope this helps.
Surgical follow up

As a coder and billing specialist, the general rule I have always followed is this: If there is NO office type visit assessed for the day (99024 has always been a NO Charge follow up) then there would be no copayment assessed by the insurance company. Remember, providers and their offices don't assess copays, insurance companies do (and this is a contract between insurance companies and the patient). Most insurance companies will only assess a copayment when there is a billable Evaluation and Management service unless the patient has a coinsurance (indemnity plans, deductibles for diagnostics, etc). As for any additional treatments, diagnostics, radiology, labs etc, it would depend on the patient's individual benefit. I simply follow this rule: If it is an E&M (office visit, consultation etc.), collect the copay. If it is any other service, allow the service to be billed to the carrier and then bill the patient whatever copayment or coinsurance is assessed by that carrier. I hope I have explained this correctly and helped in some way. I am curious to see what other people do.

Philip A. Mayo, CPC