CODING Q&A

Coding Guidance for Multi-surgeon Cases: Part 1

INFORMATION PROVIDED BY RIVA LEE ASBELL

Riva Lee Asbell can be contacted at www.rivaleeasbell.com, where the order form for her new book, Tips on Ophthalmic Surgical Coding by Subspecialty, can be found and downloaded under Products/Books.

Some of the most challenging coding questions involve how to code for surgical procedures that involve ophthalmic surgeons of a different subspecialty, or even or non-ophthalmic surgeons, such as that which frequently occurs during oculoplastic procedures. The coding varies under different circumstances, including the physicians’ subspecialties, whether or not the surgeons are in a different or the same practice, and the surgical site.

In a two-part article, part 1 reviews the guidelines for making these coding decisions. Next month I will present challenging examples of such coding.

ROLE OF MODIFIERS

Modifiers play a crucial role in these situations — and since these scenarios are not common ones in everyday practice, it is best if the surgeon masters the decision on which modifiers to use.

The first decision is whether or not a modifier is necessary.

Physicians in the same group. When the physicians are in the same group and subsequent surgery occurs in the global period, the calculation of the global period for the subsequent surgery varies according to whether a modifier is used and which one is necessary in order to receive payment for the subsequent procedure.

Physicians in a different group. Usually no modifier is needed. Your global period applies only to the surgery you perform. If you do have to perform more than one operation, then you will be in the global period of your first surgery. To be paid, you must append the proper modifier to your subsequent surgeries.

POSTOPERATIVE CARE BILLING

Q. We are a three-physician retinal practice and cover for each other for postoperative examinations. If one of us, who was not the original surgeon, finds a related complication, such as a re-detachment, can we then bill for the office visit since it is a different provider? Would we need a modifier?

A. No, you cannot bill for the visit. If the patient had never been seen by your practice and came in for a postoperative visit, it would be a new patient to you and you could code for the visit; however, if the patient is established to the practice then it cannot be billed.

MODIFIER REFRESHER COURSE

The three modifiers used to obtain Medicare reimbursement for procedures performed in the global period of another procedure are 58, 78 and 79. One of them must be appended to the subsequent surgery in order to be paid. Each modifier has definitive circumstances for which it is to be used.

Modifier 58 is used in the following three scenarios: (1) when the subsequent procedure is staged (planned prospectively); (2) when a subsequent therapeutic procedure follows a diagnostic procedure; (3) when the subsequent procedure is more extensive than the original procedure. A new global period starts. The second surgery is paid at 100% of the allowable.

Modifier 78 is used for procedures related to the original procedure, including surgery for complications. A new global period does not start. The second surgery is paid at the intraoperative value (ie, 70% of the allowable).

Modifier 79 is used when the second surgery is unrelated to the first procedure. A new global period starts. The second surgery is paid at 100% of the allowable.

MODIFIER: NEEDED OR NOT?

Physicians in the same group. With physicians in the same group, subsequent surgery in the global period requires a modifier to receive payment for the subsequent procedure.

Physicians who practice in a different groups. In these instances, usually no modifier is needed.

Physicians in the same or different session. This is tricky and for Medicare is unpredictable. Not infrequently, the case has to be taken to appeal, as high as an Administrative Law Judge hearing in order to glean payment. RP

CPT codes copyrighted 2013 by the American Medical Association.