Wiki Need advice on a global policy scenerio/issue ....

[sammartin92472]

Patient seen in observation by general surgery for consult for RLQ pain, fever & vomiting to evaluate for appendicitis. On 11.19 the surgeon clearly states in the consult "not likely surgical, will defer for further evaluation". Now, on 11.20, surgeon sees the patient again, decides that yes, the patient does need appendectomy and surgery is performed that same day 11.20. We billed the decision for surgery on the 11.20 visit. This is a 90 day global surgery which puts the eval on 11.19 at not payable since the decision for surgery was 11.20, the day of surgery. A manager is now questioning this because she feels that because the 11.19 consult clearly states no surgery that it shouldn't be used as that "pre-op" visit because the actual surgery was even decided on until the next day. Unfortunately, the guidelines state one day prior, day of and 90 days post op are part of surgical package, which would throw that 11.19 visit into the pre-op. I've been asked to appeal this because surgery was not mentioned as a possibility. I don't know, I think its a waste of time because I am thinking you can't really argue with the global policy but what are any of your thoughts? Do you see any possibility of an appeal reversing this decision and allowing this visit the day before to be paid?

 

[thomas7331]

I agree with you - both visits were within the global period and related to the surgery even if the decision was not made until the second visit, and typically payers only allow one visit for the decision prior to a major surgery. But this is one of those many areas where the language of the guidelines is not 100% clear and is open to a certain amount of interpretation by auditors, so it might be worth making your case in writing via an appeal. I've found that it's often worthwhile to submit an appeal because even if you don't win and get the denial reversed, the response can be educational and can give you additional insight into the guidelines that your payer auditors are following.

 

[sammartin92472]

Thank you Thomas. I will appeal. Seems like everytime I send one to be adjusted now it gets sent back to me to appeal. I've been surprised before by appeals that get paid when I was doubtful.