Surgical Billing & Coding - Articles

You know how to find a procedure code and you may even know how to do the procedure, but where does the reimbursement come from?  It seems to be a mystery to many of us, so let's clear up some common confusion and review some of the main reimbursement systems.  One of the ...

Critical care services remain to not only be an area of confusion for providers, coders, and auditors, but also a constant target for the carriers for audit. We can sit back and look at critical care and think of all of the ways the code descriptor and/or use could be ...

Auditing Hospitalist Services The inpatient side of coding and auditing can be enormously complex, with many more moving parts than are typically found in the outpatient setting. In this audit tip, we will discuss a few of the challenges that come with auditing one of the most important players in the ...

For hearing impairment, Medicare is firm in its stance on when it will and will not cover hearing correction. In the PUB 100-02 Medicare Benefit Policy Manual, Chapter 16, Medicare cites the Social Security Act by explaining:  "..."hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids" ...

The following table is taken from the Contract-Level Risk Adjustment Data Validation Medical Record Reviewer Guidance dated 2017-09-27 (see References). It is a listing of acceptable provider interpretation of diagnostic testing. Acceptable Examples include: Cardiology and Vascular Surgeons Echocardiogram (including Doppler, Duplex, Color flow of the heart vessels) EKG (electrocardiogram) – Stress test, Cardiac ...

Moderate (Conscious) sedation is a drug-induced state of relaxation in which the patient is typically awake and can respond to verbal commands, but might not be able to speak. A combination of medicines is used and often includes a sedative as well as an anesthetic to block pain. Prior to 2017, ...

The global surgical package is inclusive of the services that would normally be provided to the patient following surgery. Depending on the global period assigned to a CPT code, the pre-operative, intra-operative and post-operative services could be included in the global surgical package.....

The Medicare Learning Network provides guidance on the global surgical package

So you’ve read the descriptions for both Modifiers 52 and 53, but you’re still on the fence as to which one is appropriate for a certain surgical case. This brief article will try to better differentiate between these two often-confused modifiers. Modifier 53 is appropriate when a...

Modifiers in Postoperative Periods Introduction Documenting the events of a patient visit is not always the simplest and most straightforward of processes. Many variables affect which information must be included in order to report a procedure or service accurately. Global periods are one of...

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When performing minor surgical procedures, it is important to document what was done, how it was done, where it was done, why it was done, how deep, how long, and how many. In billing and reporting a procedure, document in the medical record the key components of the procedure as described by the...

Are the following statements true or false? • The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules. • The surgeon can never be paid to do a pre-op visit if s/he is going to take the patient to surgery. • The...

During the rigorous training physicians undergo to learn their craft, very little education is received on how to deal with submitting claims to insurance companies. It’s unfortunately a necessary evil, as surgeons who contract with insurance companies rely on that reimbursement as the...

Chart audits frequently examine coding associated with lesion removals and wound repairs. In order to assign the appropriate procedure code, certain documentation must be included in the medical record, such as lesion type, excision size, wound repair, and location. Without these important details,...

There are some procedures which are defined as unilateral procedures, and some defined as bilateral procedures. If the procedure is defined as unilateral but performed bilaterally, then the physician is paid 150% of the fee schedule amount when performed on both sides. If the code is defined as...

In 1992, CMS developed the concept of the Global Surgical Package, which pays for surgical services with a single payment. The full description of services that are included in this payment is described in the Medicare Claims Processing Manual, Chapter 12, Section 40 and in a CMS Fact Sheet.

Multiple Surgical Procedures In some groups, the coder performs all of the steps below. The responsibilities indicated here are opinion of the author, not law, regulation or national policy. Physician Responsibility: 1. List all codes for the procedures performed 2. Note whether the...

Modifier 24 is appended to an Evaluation and Management service by the same physician during a post op period. See the CPT® book for the complete definition. This modifier may only be used with E/M services. When a physician bills for a surgical procedure, the post op care for that procedure...

Modifier 25: Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. Refer to the CPT® book for the complete definition. Modifier 25 is appended to the E/M service, never to a procedure. The decision about whether to bill for...

By Jeannie Cagle, BSN, RN, CPC For those practices that bill consultation codes, the guidelines can be confusing. Yet, it is worth taking the time to learn the rules to get the additional reimbursement paid for consultation codes over new patient codes. Remember the following: · ...

Medically necessary pre-operative evaluations are covered services by Medicare and other third party payers. Typically, the surgeon who will perform the surgery asks the patient's primary care physician or sub-specialist to clear the patient prior to a major surgery. This service must be medically...

Bilateral Total Knees—How to Submit the Claim From Question: How do I report bilateral procedures, one line or two? Answer: Great question, unfortunately the payors have made this simple concept of bilateral procedures challenging from a reimbursement standpoint! Survey your payors...

Question: How do we code a transphenoidal hypophysectomy when we do the procedure with an ENT doctor? The ENT doctor says he has his own codes to bill. Answer: There are two codes to report this procedure. First, CPT® 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or...

Some surgical procedures may be performed with both a primary surgeon and an assistant surgeon. Insurance companies typically pay 20% to 25% for the assistant. Medicare allows 16% of the full fee payment for the assistant surgeon.

A complete colonoscopy according to Current Procedural Terminology published by the AMA is: “Colonoscopy, flexible, proximal to the splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate...

From the Q&A section: Question: I have a patient with a large (~15 cm) soft tissue mass in his flank which on initial evaluation is consistent with a large lipoma (95% sure, but I've been tricked with sarcomas before). For the excision, would I use the skin code (11406) or the...

Do not use the open code for procedure when performing the service laparoscopically. Use an unlisted code if none exists. Contact your medical society and the CPT® committee to describe the service and advocate for a code. Here is Nancy Maguire's response to this question on the Q&A...

1. As a CPT® Assistant subscriber, if you have a question that is directly related to CPT® Assistant, they will answer it. Questions can be e-mailed to cptassistant@ama-assn.org with subject - call for letters and to attention of Gloria Green per the CPT® Assistant. They ask that...

By Crystal Reeves, CPC, CMPE, Principal Modifier -59 is probably one of the most misunderstood, misused, and most-feared of all CPT® modifiers. Some practices avoid using it all together because they don’t want to be guilty of unbundling. Some practices do not use it because they are not...

If a physician removes sutures that he/she placed, and the service has a ten day global period, there is no separate payment for the suture removal. It is part of the global service and payment for the minor procedure. However, insurance companies will pay for suture removal performed by a...

The concept of paying surgeons a global payment for all services related to a surgery started in 1992, with the implementation of the Resource Based Relative Value System (RBRVS). This concept describes the components of the global package, and established the post op period for surgical services,...

Modifier 58 is appended to a surgical service to indicate that the physician performed a procedure during the global period that was planned at the time of the original procedure (staged), was more extensive than the original procedure, or is the therapeutic service following a diagnostic procedure....

Modifier 78 is used to indicate that the physician who performed a surgery which had a 10 or 90 day global period took the patient back to the OR for a related problem, typically, a complication. Do not use it for staged or related procedures--that is reported using modifier 58. For unrelated...

Modifier 79 is appended to a procedure to indicate that the same surgeon took the patient back to the operating room during the global surgical period for an unrelated problem. The second procedure must be unrelated to the original procedure. See modifier 78 for return trips to the OR that are...

Modifier 77 is used to indicate that the same procedure was performed on a patient, but the service was done by a different physician than the first procedure. Use this modifier on the same day or during the global period of the first service. Use the same CPT® code. The procedure report...

Modifier 76 is used to report the service when the same procedure is performed by the same physician, on the same patient either the same day of the previous procedure or doing the global period. The modifier tells the payer that this is not a duplicate bill, but that the same procedure was...

The global surgical package includes the care of the patient pre-operatively, intra-operatively and post-operatively. In some cases, however, the surgeon has performed only part of those services. For example, a tourist at a ski resort who falls and requires surgery will return to their own home...

Modifier 79 is used to indicate that the physician performed a surgical service that required a return trip to the OR for an unrelated problem during the global post op period. Modifier 79 is appended to procedures. See the CPT® book for the complete definition. It is appended when: A...

Modifier 57 is a modifier that is appended to an E/M service to indicate that this was the visit at which the physician decided to perform surgery. It is only used on procedures with a 90 day global period, per CMS, although this is not a CPT® rule. It is only used the day of or before a major...

Most surgeries with two surgeons are reported and performed as the primary surgeon (no modifier on the CPT® code) and the assistant surgeon (modifiers 80, 81, 82, and AS). Some surgeries, however, require two surgeons (modifier 62) or a surgical team (modifier 66). How does a physician or...

Many physicians report that it is difficult to get insurance companies to pay for skin tag removal. That is because most insurances consider the service to be cosmetic. If you are performing the service, tell the patient prior to providing the service that if their insurance determines the...

General Surgery Multiple Surgeons, Different Procedures Question: Do I use modifier 66 (team surgery) when our General surgeon is operating on a child during the same session as a plastic surgeon doing a cleft palate repair or a urologist performing a urologic procedure such as a...

Some surgeries are planned to be laparoscopic procedures, but the physician needs to convert the service to an open procedure. In that case, bill only for the open procedure. If there was significant extra work, meeting the criteria for use of modifier 22, and this is documented, then add that to...

Medicare uses different rules to pay for multiple surgical procedures and multiple endoscopic procedures. For non-endoscopic procedures, the service with the highest RVU is paid at 100% of the fee schedule, and at 50% for the second to the fifth procedure. Multiple unrelated endoscopic...