Wiki Help- E&M in global period

[vkratzer]

My boss and I have different views on billing E&M's in the post op period for complications. My boss tells me that I can bill for E&M if patient is seen for problem that is not expected to occur in the post op period such as infection, non-healing wound, etc. It is my understanding that complications are not billable in the post op period unless it is staged procedure or patient needs to return to the OR.

Appreciate any help or guidance.

Vicky K

 

[efrohna]

My boss and I have different views on billing E&M's in the post op period for complications. My boss tells me that I can bill for E&M if patient is seen for problem that is not expected to occur in the post op period such as infection, non-healing wound, etc. It is my understanding that complications are not billable in the post op period unless it is staged procedure or patient needs to return to the OR.

Appreciate any help or guidance.

Vicky K

Please check out this link in regards to global surgery modifiers. Your carrier will probably have something similar to this as well.
http://www.wpsic.com/medicare/part_b/education/modifier_global_surg.pdf
Good luck!

 

[LLovett]

Based on CMS guidelines you are correct Vicky. Complications are included in the global package and not separately billable.

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

Components of a global surgical package starts on the bottom of page 88 and complications are addressed on page 89.


Hope this helps,

Laura, CPC, CEMC

 

[RebeccaWoodward*]

My boss and I have different views on billing E&M's in the post op period for complications. My boss tells me that I can bill for E&M if patient is seen for problem that is not expected to occur in the post op period such as infection, non-healing wound, etc. It is my understanding that complications are not billable in the post op period unless it is staged procedure or patient needs to return to the OR.

Appreciate any help or guidance.

Vicky K

Based on CMS...you're correct; however, if the carrier in question follow's CPT's definition, she (boss) could be correct, also.

CPT's Surgical Package
According to CPT, the surgical package includes the following:

*The surgical procedure;

*Local infiltration, metacarpal/ metatarsal/digital block or topical anesthesia;

*One related evaluation and management (E/M) encounter (including history and physical) that occurs after the decision for surgery has been made and is either on the date immediately prior to the procedure or on the actual date of the procedure;

*Immediate postoperative care, including dictating operative notes and talking with the family and other physicians;

*Writing orders;

*Evaluating the patient in the postanesthesia recovery area;

*Typical postoperative follow-up care.

Check with the carrier...if they don't follow CMS' policy, it is possible. I would ask for their guidelines...

 

[vkratzer]

Thanks for all your help and references.

Vicky

 

[FTessaBartels]

Definitely check with carrier

I work for pediatric surgeons, so we have few (if any) Medicare patients.

We have been successful in coding /billing/ getting paid for postoperative complications such as infection. But it depends on the carrier.

F Tessa Bartels, CPC, CEMC

 

[SCanterbury]

To back up what Rebecca said, CPT allows visits to be billed to address significant complications (something more than a loose stitch). Even though these visits are related to the procedure in the absolute sense, they are unrelated to "typical postoperative follow-up."

Per the August '03 CPT Assistant:

"This modifier [24] would be appended to an E/M code when the physician sees a patient for significant complications... (ie, post-operative infection or persistent bleeding where a coagulopathy must be explored, linked to the appropriate diagnosis code to indicate the reason) or for an E/M visit completely unrelated to the [procedure]..."

You must check to see if a commercial payer has published what it considers to be part of the surgical package. Some have included wording in their definitions that mirrors that of Medicare, saying that the treatment of complications (not requiring a return to the O/R) is included. If they have, you can't bill a complication visit. If they havn't, assume standard CPT rules are in play that allow it.

Seth Canterbury, CPC, ACS-EM