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Table of Risk - If a physician is seeing a patient

  1. #11
    Location
    Columbia, MO
    Posts
    12,527
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    Medical Coding Books
    Quote Originally Posted by sparkles1077 View Post
    We often have specialty providers doing preop clearance. For example, a cardiologist may need to clear a patient for neurosurgery or dental. They bill E and M codes for these visits - they are not part of the global because they are a different physician and specialty
    Different physician and different specialty does not mean they are not part of the surgical global. They are participating in a defined portion of a global event, the pre operative portion. Which is why there is a modifier for this portion, the 56. That modifier does append to the surgical code as Laura states for any physician that is performing the preoperative portion of a surgery at the request of the surgeon. If you do not perform the total compliment of the pre op then you can append a 52 as well to show you did not perform the complete pre op.
    Many payers will recognize this modifier and the reimbursement is anywhere from 10 to up to 20 percent of the global, AND the surgeon's global reimbursement will be reduced by this amount.

    Debra A. Mitchell, MSPH, CPC-H

  2. #12
    Location
    Lynchburg, Virginia
    Posts
    27
    Smile Table of Risk
    Quote Originally Posted by colorectal surgeon View Post
    A high level of risk is major surgery with risk factors? What does that mean exactly? I believe it is supposed to be patient risk factors, not surgery risk factors?

    I have heard before that the diagnosis must pertain to that specialty? So I am not able to list hypertension, osteoarthritis and get credit for these since I'm not managing them? However, when evaluating a patient for surgery, these play into the risk in my mind. But they may or may not when I'm treating something minor, hemorrhoids or other anorectal problems in my specialty.

    Any comments?
    It is supposed to be patient risk factors and not surgery risk factors. And I would agree that if you are treating minor complaints such as hemorrhoids or other anorectal problems, you should not code hypertension, etc. Those types of conditions would not increase patient risk for loss of life/bodily function in such unrelated minor problems. But if you are doing a pre-op evaluation, hypertension, diabetes, etc. are all risk factors for the patient and should be documented. Wouldn't it be neglectful to do otherwise?

    Just thinking...

    Janice Brashear, CPC

  3. #13
    Location
    Lynchburg, Virginia
    Posts
    27
    Smile Global period
    Quote Originally Posted by mitchellde View Post
    Different physician and different specialty does not mean they are not part of the surgical global. They are participating in a defined portion of a global event, the pre operative portion. Which is why there is a modifier for this portion, the 56. That modifier does append to the surgical code as Laura states for any physician that is performing the preoperative portion of a surgery at the request of the surgeon. If you do not perform the total compliment of the pre op then you can append a 52 as well to show you did not perform the complete pre op.
    Many payers will recognize this modifier and the reimbursement is anywhere from 10 to up to 20 percent of the global, AND the surgeon's global reimbursement will be reduced by this amount.
    The 2011 AMA CPT(r), p. 52, defines the E&M portion of the surgical package as follows:

    Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical).

    So, if a provider, regardless of specialty, performed a pre-operative examination for clearance of the patient two days or one week prior to the surgery, wouldn't that exclude that service from the surgical package? And wouldn't the provider use a regular E/M (99201-99215) or a consultation code (99241-99245), if services were requested by the surgeon?

    Janice Brashear, CPC

  4. Default
    Quote Originally Posted by jbrashear View Post
    The 2011 AMA CPT(r), p. 52, defines the E&M portion of the surgical package as follows:

    Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical).

    So, if a provider, regardless of specialty, performed a pre-operative examination for clearance of the patient two days or one week prior to the surgery, wouldn't that exclude that service from the surgical package? And wouldn't the provider use a regular E/M (99201-99215) or a consultation code (99241-99245), if services were requested by the surgeon?

    Janice Brashear, CPC
    I would agree Janice. The surgeon would still complete the preop history and physical exam. These services are clearance for surgery requested by the surgeon. Perhaps the verbiage "preoperative" is confusing. The surgeon is actually requesting a consult from the specialist. We do not add the modifier 54 in these situations.

    Diana, CPC
    Auditor at Private

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