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AAOS Now

Published 7/1/2009
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Mary LeGrand, RN, MA, CCS-P, CPC; M. Bradford Henley, MD, MBA

Check your schedule for an audit time bomb

Correctly code postoperative visits outside the global period

Did you know that the way your practice schedules postoperative visits (CPT 99024) can represent an audit risk? CPT code 99024 is described as “Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.” The timing and coding of these visits first came to attention as a coding/audit risk in 2008.

Routinely scheduling a postoperative visit on day 91, 92, or 93 when a surgical procedure has a 90-day global period is likely to attract the attention of the Office of the Inspector General or the Recovery Audit Contractors. So it’s important that your staff enters all of a patient’s 99024 encounters appropriately.

Take, for example, a hip replacement (CPT 27130). The Medicare valuation of 37.70 facility relative value units (RVUs) allocates a percentage of the payment to each component of care (Fig. 1). The allocation for postoperative care includes payment for all related postoperative evaluation and management (E&M) services within 90 days of the procedure.

Practices that schedule fewer postoperative visits than the standard may contribute to the lowered value of the code. When services are assigned RVUs, the American Medical Association’s Relative Value Update Committee (RUC) surveys physicians about physician work and practice expenses required to provide a service. Data for code 27130 show that four outpatient postoperative office visits are included in this service.

Scheduling troubles
For example, you see a patient three times during the 90-day global period. The fourth visit, in your mind, should be the last postoperative visit during the global period. But the next available appointment is on postoperative day 91. At 91 days, the patient is no longer in the global period, so your staff may schedule the appointment as an established patient visit and not a 99024 postoperative visit.

Even if the checkout staff schedules the visit as a postoperative global period, another staff member who is checking patients in or preparing charts may notice that the patient is no longer in the global period and change the visit from a postoperative visit (99024) to an established patient visit (9921x). You circle a return visit on the encounter form or enter it into the electronic medical record using a diagnosis code of V54.81; V43.64. Even if the diagnosis code is the same as during the post-operative global period, the risk is that 9921x is reported instead of 99024.

A similar situation could occur when you see a patient, order a return visit (the final visit included in the global period), and the patient doesn’t mention that this is the “final postoperative visit.” When the scheduler sees you are on vacation, she sets up the appointment on day 93. Finally, the patient may not be able to make an appointment within the global period and requests an appointment on day 94.

When the last visit occurs outside the global period, it is often scheduled as an established patient visit and a claim is submitted. The diagnosis code in these scenarios may be the same because the patient is receiving follow-up care after the total hip arthroplasty.

Don’t make it a habit
It’s the pattern and the frequency of these submissions that count. If this happens occasionally, no audit cop will come knocking. On the other hand, some practices have a scheduling policy in writing or built into the computer appointment template. If your policy is to “schedule final return visits after the 10- or 90-day global period,” you need to call a healthcare attorney for advice.

Shredding or destroying that policy won’t reduce your risk because staff “who follow rules by the book” will testify that they scheduled the appointments according to the policy. When questioned by a federal agent, staff will probably state, “I just did what I was told.”

In some practices, staff will bill for these pseudo visits, payors will reject the claim, and no one mentions it to the doctors. Thus, there’s no financial problem. In other groups, the practice of scheduling and billing for the last postoperative visit isn’t officially sanctioned, but is the habit of one or two physicians. Group practices should audit their schedules to assess whether risky behavior by a few members is putting the entire group at risk.

When you see patients during the postoperative global period, you should report or enter CPT code 99024. Entering this code in your practice management system reflects care provided during the postoperative period. Payors, particularly managed care or capitated plans, may require this documentation to substantiate charges or capitation payments.

Be sure to document all services and, because 99024 is a nonpayment CPT code, ensure that the charge is 0. If the payor does not require submission of 99024, set up the practice management system to allow the code to be posted, but turn off the feature to transfer it to the claim form.

Continuity of care
In this example, Dr. Jones performs a hip arthroplasty on a Medicare patient on June 1. On June 10, when Dr. Jones is out of town, the patient returns with a full-blown surgical site infection. Dr. Jones’ partner, Dr. Smith, evaluates the patient, cleans the wound, and orders antibiotics. Dr. Smith circles 9921x on the encounter form and links to the diagnosis of “postoperative wound infection” (998.59). Even though the care of the patient is the responsibility of the group, Dr. Smith reasons, “it wasn’t my patient.”

Staff enter the code and the charge, but the front-end edit system rejects the visit because it occurred during the global period. The claim is “fixed” when the coder adds modifier 24, because the diagnosis of postoperative wound infection is “different” than the diagnosis for the hip arthroplasty. Whether this overrides the edit or not, if the claim is paid, the risk exists that a retrospective payment audit will result in the payor requesting a repayment.

If, however, either Dr. Smith or Dr. Jones sees the patient on a day close to but beyond the global period because that’s when the patient called with a problem, the visit would be billable. Why? Because the patient came to the office outside of the global period for an unscheduled visit with a problem.

Next steps

  • Run an audit on your surgical patients to determine the number of postoperative visits you are billing as 99024 and when the first 9921x is reported after the global period.
  • Revise any scheduling policy that instructs the postoperative visits to be scheduled after the global period. If you do not have a scheduling policy, create one that complies with the global surgical package definition. If a patient’s next appointment should be part of the global period but falls outside the global period, schedule it as a postoperative visit and include an explanatory comment in the notes.
  • Look at the use of modifier 24 during the global period. Run a CPT frequency for 99211-99215 with modifier 24 and include the diagnosis. Review all services where the diagnosis appears to be at the same site or closely related to the anatomic location of the surgical procedure.
  • Run a second audit to ensure that all follow-up visits by surgical patients to your practice are coded under the 90-day global surgery code, regardless of which physician is seen.

Optimizing your reimbursement is critical during these economic times, but not at the risk of incorrect coding or billing activities. Code accurately, submit dictation and claims on a timely basis, and ensure accurate claim submission to payors. You’ll minimize risk and be paid faster.

The OIG Work Plan discussion of evaluation and management during the global period (PDF file)

Mary LeGrand, RN MA, CCS-P, CPC is a consultant with KarenZupko & Associates, Inc., and focuses on coding and reimbursement issues in orthopaedic practices. M. Bradford Henley, MD, MBA, is a member of the AAOS Coding, Coverage and Reimbursement Committee.