Coding Questions? We’ve Got the Answers

By Bill Dacey

Hospitalist admit billing

Q A patient presents at the emergency room with a hip fracture. The orthopedic surgeon is called and he states that he cannot be there for two hours, and he then asks the hospitalist to admit the patient. The hospitalist does so. Here’s my question: Can the hospitalist perform and bill for the admission if the patient has no other medical reason to be admitted to the hospital other than the hip fracture? Also considering that the orthopedic surgeon will be billing a global CPT code for the hip repair?

A There are a lot of variables here. First, there is no definitive answer because every payer interprets these things differently. Do you want the Medicare answer? If so, what carrier? That’s probably what you want to know.

The patient is going to get admitted anyway. In the normal course of events the orthopedic surgeon would have done an ED consult, billed it with a -57, and let the admit go as part of the global, assuming surgery was done. He later would have likely turfed medical management of the patient’s problems to the hospitalist anyway, which would have been a subsequent visit on that same day.

In this delayed scenario, if the orthopedic surgeon thinks the patient needs to be admitted and stabilized by the hospitalist, then that should be enough. The orthopedic surgeon will then show up and do the surgery — and bill globally.

Don’t try to make a science of this; you have to deal with these events as they unfold, rather than define or pigeonhole the coding for every configuration of events.

Coding for pre-op exam

Q We are a primary care and endocrinology/diabetes group who is asked by various surgical offices to do preoperation exams and surgical clearances for our patients. The pre-op usually includes EKG with interpretation, lab work, and plan of care assessment pre- and post-op. After attending a recent coding seminar we realized we were not coding these correctly and should be asking, at the time of making the appointment with the surgical office, for the surgical code(s) and adding a -56 modifier on our billings, then as a courtesy reminding the surgical office to also add a modifier to their billing. Most offices seem aware of this and are happy to comply, and we have indeed received our portion of the fee from various insurance companies. We have run into some resistance with one group in particular, which leads us to some doubt and need for verification from an expert coder. Are we in fact coding/billing surgical clearances correctly now, or do we go back to billing E&M codes?

A I don’t know where you got this guidance, but I don’t think it’s the best. There is no single source of direct authoritative guidance I know of that says don’t do this, but there’s plenty of anecdotal direction.

The pre-op component of a surgical procedure is intended to be the preoperative services normally associated with that procedure, and performed by the provider performing the surgery. That is why it is part of the global package — it is part of those pre-op services normally included in the package. Most Medicare carriers also do not recognize modifier -56, if that says anything.

The services provided by a primary-care provider to clear a patient for surgery are services to assess the other problems the patient may have, any problems or conditions that may impact risk or contraindicate surgery, or those that simply need to be cleared. It is a separate assessment, or potentially different problems not related to the reason for the surgery, performed by a separate provider. It has long been recognized as best represented by a consult code in terms of code type.

Selecting high vs. moderate risk

Q I have kind of a technical question for you. Under the Diagnostic Procedure(s) Ordered column on the Table of Risk you have:

• Moderate — Cardiovascular imaging studies with contrast and no identified risk factors, e.g. arteriogram, cardiac catheterization
• High — Cardiovascular imaging studies with contrast with identified risk factors

A cardiologist orders a Myoview stress test, a nuclear study on a patient with an abnormal EKG to rule out coronary artery disease. The patient also has diabetes mellitus, hypertension, hypercholesterolemia, which are all stable at the time. Are these additional risks adequate to select a high risk?

Endoscopy has the same distinction relative to risk factors — moderate versus high risk. I never really know what to do about this. I have asked this question of several coders and no definitive answer has been given.

A There’s a reason that coders have likely been unsure here, and it’s because they probably don’t have a good sense of the risk that any given comorbid condition creates.

The middle column of the Table of Risk is tricky for two reasons: First, it contains examples of things that may represent a given level of risk (like the entries in the other columns), rather than a definitive measurement; and second, it depends on a given provider’s opinion relative to what risk is entailed with a given procedure, and may more importantly depend on the ability of a nonclinician auditor to recognize it.

Simply ordering a given test, and mentioning comorbid problems likely does not resonate with all reviewers, or resonate the same with all other clinicians. In my opinion what you need to do is to make a clear statement that the patient is at a given level of risk, use the words “moderate” or “high,” relative to a specific differential, diagnosis, or procedure.

In a Medicare document outlining medical necessity requirements we find the following statement: “Demonstrate clearly how physician work (expressed in terms of mental effort, physical effort, time spent, and risk to the patient) was affected by comorbidities or chronic problems listed.”

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