Family physicians often find themselves collaborating with surgeons when their patients need surgical procedures they don’t provide. Because Medicare and other payers bundle payment for the various services associated with a surgery into a single payment (see “Spanning the Global Surgical Package,” FPM, September 2003, page 18), family physicians are sometimes confused about how to bill for their services when a patient undergoes surgery. This article attempts to eliminate some of that confusion.
Office visit vs. preoperative consultation
Prior to surgery, the surgeon may send your patient to you for preoperative clearance. This generally occurs when the patient has comorbid conditions (e.g., hypertension or diabetes), and the surgeon is otherwise concerned about the patient’s fitness for the procedure. In this situation, it is appropriate to submit a consultation code for the preoperative clearance, as long as the service meets the definition of a consultation. According to the CPT manual, a consultation is “a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.” In the case of a preoperative clearance, a surgeon is typically requesting your opinion or advice regarding the patient’s fitness for surgery.
To code a consultation for this service, you must document the surgeon’s request, your advice and any services ordered or performed; you must also provide a written report to the surgeon. Keep in mind that consultation codes apply to both new and established patients. If you provide other preoperative services during the consultation (e.g., an ECG), you should code for those services too.
When billing Medicare for a consultation, be sure you also submit the appropriate diagnosis codes. Choose a code from the V72.81-V72.84 series (preoperative exams) as the primary diagnosis. The secondary diagnosis should be the reason for surgery. Any other diagnoses and conditions affecting the patient (e.g., the specific problem evaluated) should be listed as the third and subsequent diagnoses. Although other payers may follow the same convention as Medicare, some may require the relevant diagnoses in a different order (e.g., the condition prompting the consult first).
You may also want to have your Medicare patients sign an Advance Beneficiary Notice (ABN) if you think the service may be denied for lack of medical necessity (see “Using Advance Beneficiary Notices to Maximize Your Medicare Collections,” FPM, September 2002). This will permit you to bill your patients directly if Medicare denies payment.
When a preoperative clearance does not meet the definition of a consultation, simply code the encounter using an office or other outpatient visit code (99201-99215). For example, a patient presents with a history and physical form that the hospital needs and you provide the history and physical. In this scenario, it is not clear that the patient’s surgeon has asked for your advice or opinion regarding evaluation or management of a specific problem. Since this is a prerequisite for using a consultation code, this visit doesn’t meet the definition of a consultation. Submit an office or other outpatient visit code (e.g., 99214) instead, depending on the level of history, exam and medical decision making involved. If you have any questions about whether the surgeon is requesting a consultation, contact the surgeon to clarify the situation.
Coding for the hospital admission
The work of the hospital admission is generally considered to be included in the global surgical package. As such, it is generally the surgeon’s job to admit the patient to the hospital for the procedure and perform the associated history and physical. However, in the case of an itinerant surgeon or a patient admitted for medical problems that subsequently require surgery, you may be the one who admits the patient and does the associated history and physical. In this case, you should bill for the admission using the appropriate initial hospital care code (99221-99223).
Assisting with surgery
Sometimes you may be asked to assist with a surgical procedure. To code for this, you should add modifier -80, “Assistant surgeon,” to the surgical procedure code. For example, you may be asked to assist with a hysterectomy on an obese patient. In this case, use code 58150-80. Payers will typically pay physicians assisting with surgery a percentage of the fee otherwise paid for the global surgical service. For example, the Medicare fee schedule amount equals 16 percent of the amount otherwise applicable for the global surgery.
The global surgical package includes payment for typical postoperative care. The surgeon who performed the surgical procedure is generally presumed to be providing the postoperative care.
In some situations, however, you may be involved in the postoperative care. For example, a patient who underwent hip replacement surgery may develop cardiac problems that the orthopedic surgeon is not comfortable handling. If the surgeon asks you to assume responsibility for the patient’s care, you should code your services using the appropriate subsequent hospital care and office visit codes (99231-99233 and 99201-99215, respectively). If the surgeon simply requests your advice about how to manage the problem and you document this request and provide your advice in writing to the surgeon, you should code these services using the appropriate consultation codes (99251-99255 and 99261-99263 for inpatients; 99241-99245 for outpatients).
Be aware, however, that Medicare and many other payers will not reimburse you for both a preoperative and a postoperative consultation on the same patient for the same episode of care. If you’ve provided a preoperative consultation and the surgeon calls you in for a postoperative consultation on the same patient, you will need to code your services using either a subsequent hospital care or office visit code, depending on the site and service.
You may also find yourself providing postoperative care for a patient who has had surgery outside your local community. In this situation, it may be unfeasible or impractical for the surgeon to provide the typical postoperative follow-up care. If you provide the typical postoperative care instead of the surgeon, you should bill your services by appending modifier -55, “Postoperative management only,” to the code for the surgical procedure. Using the hip replacement example above, you would bill your postoperative services using 27130-55. To indicate that the surgeon did not provide the global surgical service in this circumstance, he or she should report the surgical code with modifier -54, “Surgical care only,” attached.
Note that for Medicare and some other third-party payers, coding postoperative follow-up care with modifier -55 implies a transfer of care from the surgeon to you. Where a transfer of care does not occur, Medicare and other payers may require the occasional postoperative services of a physician other than the surgeon to be reported with the appropriate E/M code.
When you are providing all or part of the typical postoperative follow-up care, it is a good idea to contact the patient’s insurer to verify how your services should be billed. Before coding postoperative follow-up care with modifier -54, it is also a good idea to communicate with the surgeon’s office to coordinate your respective claims so you both use the same surgical and diagnosis codes and so they don’t bill the service globally.
Coding and billing for your services when you are the only one involved is tough enough. Doing so when a surgeon is also involved makes it that much tougher. However, it’s worth the effort to learn how to code for these services so you are appropriately paid for the work you do.