Wiki Pt in 90 Day global but returns as an inpatient

[jscot76@wgu.edu]

My question is pertaining to a patient who was three weeks post op for partial lt nephrectomy, surgery diagnosis D41.02, returning to the hospital admitted as in patient with left flank pain, perinephric hematoma, and gross hematuria. The doctor documented the visit but is stating that since this is within the global period he cannot charge for the visit. Am I wrong in thinking he can bill for the visit with a modifier 24?

 

[pamsbill]

Was it related to the surgery?

You have to remember, the payment for the surgery includes post-op management. Some post-ops will be difficult, some will be a breeze. Supposedly, the payment for the surgery takes into consideration the range of possible post-op complexities and averages it out. For cases where the post-op period was easy, one makes out. For cases where the post-op period was difficult, not so much. It all averages out over time. (At least that is the theory behind it.)

 

[Rajashree.Navgire@gmail.com]

visits in post op period

In the above case study ,pt is returning to ip in global period if the problem is not related with surgery them billed out the e/m level with 24 modifier.

 

[mitchellde]

You don't know that these conditions are not related to the surgery. We do not have the entire note. These all look like symptoms that could be related to a post nephrectomy patient. If the provider feels this is a related post operative encounter, then to use the 24 would be incorrect.

 

[AlaskanCoder]

AAPC has a really great Webinar which gives some insight into when to use modifier -24. The webinar is called "Coding with Modifiers: CPT, Medicare and the Real World" and was put on by Timothy Canterbury, CPC, CPC-I. He explains that the CPT definition of the surgical package includes "Typical" post-op follow up. Since returning to the hospital as an IP 3-weeks post-op is not typical, this would suggest that this service is not included in the surgical package definition and should be reimbursable. Mr. Canterbury cites CPT Assistant which says that E/M services for complications that require significant additional work are appropriate to be separately reported with modifier -24. However, CMS has their own interpretation of the surgical package and say that they have taken into consideration that there will be times where time additional services will be required due to complications and they have computed this into the CMS reimbursement of the surgical package. So, depending on your payer, there are times when you can, quite appropriately bill for E/M services for complications from from/of a surgical procedure using modifier -24. CMS specifically states, though, that if the E/M is due to a complication it is related to the initial procedure and modifier -24 is inappropriate.
The webinar also discusses the appropriate uses of modifiers -58, -78 and -79, among others. I highly recommend it.
However, I will say that I agree that if the provider feels that the services in this admission are included in the surgical package, regardless of the payer, then the service should not be billed from an ethical viewpoint.

Karen Hill, CPC, CPB, CPMA, CPC-I