Wiki NP billing E/M codes pre and post op

[mizali]

I was just hired to do billing for a surgeon and NP that are part of the same group practice. They do their own coding. The NP bills the E/M codes (office visits, ER, hospital admits) and the surgeon performs the surgeries. The NP then sees the patients for their follow-ups and bills E/M codes while in the global periods. (instead of 99024) They each have their own NPI, but share the same tax ID. They tell me they have always done this, but this doesn't seem right to me. The NP uses mods 57 and 25 on his E/M codes. I thought those could only be used when the same practitioner that provides the E/M service also performs the major/minor procedure?

 

[stheck]

Are you sure they are being billed this way?

The -25 is for "significant, seperately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.

-57 "decision for surgery" is used if a patient is already being seen by a provider and the decision is made that day to do the surgery.

If the office visits are not on the same day as the procedure then there is no need to use the -25, and the -57 should only be used if they decide to do the surgery that day...

I have some questions?

Are they billing the NP visits "incident too"? - Which providers name is on the claim?
If only the NP's name is on the claim then they are being paid at a reduced rate anyway...
Has the doctor performing the surgeries ever seen the patient?
Are other problems (not relating to the surgery) being addressed within the global period?
Are there any complications with the surgery?

-79 is the modifier stating an "unrelated procedure or service by the same physician during a postoperative period"

-24 is "unrelated evaluation and management service by the same physician during a postoperative period".

 

[mizali]

Thank you for your reply.
The NP does not bill "as incident to". My concern is if it is acceptable for the NP to charge for E/M codes on patients that are in global periods for services provided by a surgeon in the same group practice. Assume the NP's services ARE related to the surgeries.
In most cases I've seen, the NP is performing the H&P prior to the (scheduled) surgery either in the office setting or in the hospital and bills an office visit or admit. Sometimes the NP will append modifier 57 to his charge, and the surgeon will do a procedure that day or the next. The NP also does a majority of the follow ups with the patient and charges an office visit for that too instead of 99024. If it were the surgeon following up, he could not charge for an office visit unless the visit was unrelated to the surgery and used modifier 24. When the NP uses modifier 24 on the unrelated visits, is that correct if he was not the provider that performed the surgery? It's very confusing!

 

[Pam Warren]

You're on the right track and your gut told you this was wrong. It is very wrong.
Providers of the same group are considered inclusive as part of the global surgery package. You should not be billing an E&M post-operatively for these patients who continue to be in the global period for surgery done by the physician of the same group, unless the E&M is separately identifiable....meaning different problem, not different provider or common post-op complication. It doesn't matter if billing incident-to or not....the NP cannot bill during the global period for patients in your same practice for post-op care. One of the reasons surgeons use mid-levels is that they can handle the unbillable post-op services, freeing up the surgeon's time. From a patient care perspective, the surgeon should be making the decision for surgery, whether or not the -57 is appropriately used. Arbitrarily using the -25 and -57 to override claim edits is considered questionable (I'm not going to use the 'F' word here) business practice.

My advice is to immediately contact your payers and refund the money that's been billed separately during the global period, and then create a coding/billing policy to outline the correct way to bill these. If your surgeon/NP disagrees and directs you to continue to bill this way, get yourself a new job. You've unbundled these surgeries, which is high on the OIG's workplan (always). Then read through the instructions for the CCI edits, as well as the introduction in CPT's surgery section, and the information on modifiers. Then get yourself to some coding/billing training with regards to surgical coding. You shouldn't be tackling this without a solid understanding of surgical coding.

 

[mizali]

Thank you both for your input and advice. I will be discussing this situation with my supervisor.