DAVID STERN, MD (Practice Velocity)
Q.I was curious about your response to a case listed in Coding Q&A in the November issue of JUCM. The case described a patient who returned for reopening of a wound due to infection. The physician then cleansed and re-sutured the wound.
Although I agree about the postoperative care in general, I wonder if modifier -79 would be appropriate in these circumstances.
According to instructions by the AMA, this modifier may be used for circumstances when the service is not related to the original service. The infection of the wound is not part of regular global package services. If they had used the diagnosis of wound infection (a different diagnosis from the original service) along with the appropriate CPT, I wonder if this would have resulted in payment.
– Questions submitted by Elaine D. Wade, BSN, CCS-P, Presbyterian
Health Services
A.What you describe may be a compliant method for obtaining payment for payors not governed by Centers for Medicare and Medicaid Services (CMS) rules.
Unless the payor has specified otherwise, you can follow the AMA rules for coding of global services. The AMA guidelines state that only routine follow-up care is included in the global period, so many payors may allow you to bill for additional procedures related to complications that occurred during the global period. In the specified case, the payor was Medicare so all fol- low-up care (including, “complications following surgery, which do not require additional trips to the operating room”) is included in the global period.
If the patient was actually taken back to a true “operating room” for a procedure, then one would use modifier -78 (Return to the operating room for a related procedure during the post- operative period) to the procedure code. A “minor treatment room” (i.e., a typical procedure room in an urgent care center) does not qualify as an operating room. CMS makes this point in its definition of an “operating room” in the context of a global period (see www.cms.hhs.gov/manuals/downloads/clm104c12.pdf):
An “operating room” is defined as a place of service specifically equipped and staffed for the sole purpose of performing surgical procedures. The term included a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit unless the patient’s condition was so critical there would be insufficient time for transportation to an operating room.
What about the use of modifier -79 (Unrelated procedure of service by the same physician during the postoperative period)? Yes, it may aid in receiving payment, and private payors may allow you to use this modifier in this way.
However, for CMS payors, modifier -79 is only for procedures that are completely unrelated to the original procedure. Procedures that are for treatment of complications of the original procedure are not truly “unrelated” to the original procedure, so modifier -79 does not apply to these procedures. NOTE: The specific question that was addressed indicated that the wound was not resutured. It was simply opened and rechecked several times. No second procedure was performed.
Even so, under the AMA definition of the care included in the global period (but not under CMS rules for the global period), one could code an E/M for each recheck for the complication. Your payor may allow you to use modifier -24 (Unrelated E/M service by the same physician during a postoperative period) in this situation, but in the case of Medicare this would not be an appropriate use of modifier -24, as a wound infection is actually related to (i.e., a complication of) the original procedure.
Q.I recently attended the UCA Conference in Chicago. In one of your seminars, we discussed new vs.
established patients.
Our facility uses physicians that have their own separate practices. It is my understanding that if a physician has seen a patient in his or her office and then that patient is treated here by that physician, then for coding purposes the patient is treated as an “established” patient. Since we do not have access to the other records, how are we protected with such a limited exam? How do we support the documentation of an established visit when they are essentially a new patient?
One of our challenges is determining if and when they have been seen at the other practice. Since there is no relation between the two practices, we would have to depend on the physician’s memory, the patient, or request records from the office.
– Questions submitted by Abbi Olson, Urgentcare/Corpcare
A.The provider should do whatever history/exam is indicated (whether the patient is new or established) and code accordingly. The fact that the patient is “established” does not mean the provider should do a limited exam. A full history and physical may be necessary.
You will need to make your “best reasonable” efforts to determine if the patient is new or established with any provider. The method that you describe may be the best approach that is actually feasible in real life.
It would be ideal to get a full database of the patients from the other practice where the provider works. That would give you a full proof method to check for established patients. Absent receiving an actual patient database, maybe you could ask the other practice to check each day’s list of patients against the other practice’s patient database.
