Understanding Global Billing in a Group Practice

Q: Our doctor ordered a diagnostic colonoscopy because the patient was 'due for 5-year repeat given adenoma of 6mm on last procedure in 2011.' The patient is being screened for colon cancer, but at an interval of five years instead of 10 because of the polyp. The patient's insurance covers screening colonoscopy.  The patient would like the doctor to change the referral from diagnostic colonoscopy to screening. Thoughts?

A: What this comes down to is the patient wanting insurance to cover the procedure.

With a Z98.89, h/o colonoscopy with polypectomy submitted with the procedure and maybe even the pre-authorization, it becomes diagnostic. The larger view is that the 'screening' scope is a scope in the absence of a reason to suspect a problem - you have a reason to suspect a problem. So if you change it you are gaming the insurance to get them to pay (fraud/racketeering). 

Q:  We've been getting [recovery audit contractors] related to global billing. We are told that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; so if you see your partner's patient post-operatively, you cannot bill for that visit.

My lead physician says, "If I consult on a patient with for instance, pseudotumor cerebri, and send them to have surgery to protect vision in the right eye, I must still follow them for their vision in the other eye. This must not be absorbed into the global, as I am following them for the original condition, but not just in the surgerized eye. I assume this one can be appealed if they ask for their money back?
The same is true if I diagnose a pituitary tumor. When I see them after surgery, I am seeing them to attend to a whole different organ system (the eyes/vision) than the pituitary gland. I'm not in the global am I?A: The 'what you are told' part is verbatim CMS guidance and is correct per their guidelines. These appear to be somewhat hypothetical questions, but there are some nuances within them that can change the answer.

As regards the first case, the pseudotumor cerebri, where the patient is sent to 'have surgery' to protect the right eye - who was the surgeon doing the surgery? If that surgeon is in the same group and of the exact same specialty (neuro-ophthalmology), any follow up that Dr. A does on that surgerized eye is included in the global. This is the only permutation of these circumstances where the global period applies to Dr. A.

We need to know the exact specialty of that surgeon. As to case one, the surgical period does not apply if:

- The other surgeon is not a neuro-ophthalmologist

- Dr. A is following up on the other eye

You might also make also make a case that even if Dr. A were following up on the original condition of the surgerized eye, he is doing a medical evaluation of the original condition and not the normal follow up care for therapeutic surgical procedures. The definition of the latter is, 'follow up care for therapeutic surgical procedures includes only that care that is usually part of the surgical service'. His follow up is not of the surgical service, but of the medical condition.

That is likely moot as conditions one and two above most likely apply.

In the example of the pituitary tumor, the likelihood is even higher that Dr. A's services are distinct from the global period. Here a neurosurgeon most likely removes the tumor, and the global period applies to that service alone. They are separated by specialty and the problems that each addresses.

Every specific case or set of actual events will have a right or a wrong answer regarding the applicability of the global.

Q:There is a current debate in our office regarding infusion pump disconnect billing.  The nurses want to bill 96521, however billing staff disagree we believe the disconnection of the pump should be a 99211.  The office is flushing and disconnecting the pump.  Since 96521 states refilling and maintenance, we did not feel it was appropriate as they were not performing a refill.

Here is the body of the note completed by the nurse:

'The patient presented with the mediport accessed and the home infusion pump in place. The port was flushed and the home pump was dc'd. A CBC and a CMP was drawn for the pt to seen on Monday.'

A: You are right that the language does not seem to match. I'd be uncomfortable using the refill/maintenance code for unplugging it, but it's always possible that a given payer would allow this in their definition of maintenance.

In looking into the CPT Assistants there is no specific guidance there. In looking up a policy for the actual infusion code 96416 to see if the policy stated if the disconnect was included, there is no language to that effect. A non-authoritative Q & A article found online refers to a Medicare policy - but I can't locate that policy.

"Question: Can we bill when the patient comes in to have the pump disconnected?

Answer: According to Medicare policy, if the patient comes in to the office for the sole purpose of having a pump unhooked by a nurse, a level-one office visit (99211) may be billed."

Since you are clearly not refilling the pump, you are not entitled to the whole value of the code. The Medicare fee schedule (MFS) amount for the 96521 is in the neighborhood of $120.00. The MFS for a 99211 is about $20.00.

Since there is no code that exactly describes what you are doing, CPT would have you bill either an unlisted code, or use a modifier if appropriate. A modifier 52 for reduced services would be appropriate here. Then you will know exactly how much the payer values this service. It may end up being close to the 99211. This is a judgment call, but as above – you do not meet the definition of the whole code.