Determination for surgery

A notation to schedule surgery for both eyes can ‘sabotage’ reimbursement for the second eye exam.

Your patient had cataract surgery 10 days ago with excellent results. The patient returns for a postoperative evaluation on the operated eye. At the same visit, the patient complains about poor vision in the fellow eye and imbalance between the eyes. She desires cataract surgery for the unoperated eye.

Is this visit billable during the postop period of the first operation? If so, how?

Since cataract often develops in both eyes at the same time, it is important to note that the determination for surgery must be made prior to each procedure. The initial evaluation before the first cataract operation does not establish the need for the second operation. The surgeon might say, “After we finish the first operation, if all goes well, we’ll consider another cataract operation on your other eye.” Since the patient and the surgeon hope for a good outcome, but it cannot be guaranteed in advance, the surgeon needs to re-evaluate the patient a second time.

Under Medicare’s definition of the global surgery package, the determination of the need for surgery is reimbursed separately from the surgery itself (MCPM, Chapter 12, §40.1.B). If the second evaluation occurs within the post- op period of the first cataract operation, then modifier -24 should be appended to the CPT code for the office visit. If the second evaluation occurs on the day of surgery or the day before, then modifier -57 should also be used. Some surgeons presume that the second decision for surgery, particularly when it occurs within the postop period, should be free or have received conflicting instructions from carrier personnel to that effect. Since the inception of Physician Payment Reform in 1992, a homogeneous national policy has replaced diverse carrier instructions and clarified this issue in favor of physicians.

While it is clear what should happen, there have been unfortunate situations where the notations in the chart note sabotage the reimbursement for the exam prior to the second cataract operation. This occurs when the surgeon writes “Schedule cataract surgery OU” in the plan prior to the initial operation. The implication is that the decision for both surgeries has already been made.

It is important to note that the work-up for any surgical procedure includes a preoperative exam and history and physical (H&P). In some instances, the H&P is separately billable. The determining factors include who performs the service and when and why it is being offered. Medicare addressed the topic of H&Ps in a revision to the Medicare Carriers’ Manual (Part 3, 15047). Pertinent sections of the regulation are excerpted below.

Section 1862(a)(7) of the Social Security Act excludes payment for “routine physical checkups.” Both physical exams and diagnostic tests performed in the absence of signs or symptoms of illness or injury may be denied as a routine physical check-up. That having been stated, a simple H&P consisting of explanation of risks, benefits and alternatives to surgery, informed consent and a physical exam to screen for contraindications is generally considered part of the global package. In these cases, the patient is relatively healthy and the exam includes little more than measuring pulse, blood pressure, respiration and noting the patient’s medical history. The surgeon often performs this exam.
“Medicare will pay for all medically necessary preoperative services, … evaluation and management (E/M) services performed that are not included in the global surgical package for the purpose of evaluating a patient’s risk of preoperative complications and to optimize preoperative care.” Preoperative exams may be billed using an appropriate CPT code (eg, new patient, established patient or consultation). For patients with more complicated health histories, preoperative clearance may be necessary. The surgeon may perform this service or refer the patient to his or her primary care physician or another specialist to reassess the patient prior to surgery. These exams are not screening for a possible contraindication. Instead, they serve to ensure that other systemic conditions are well-controlled and do not pose additional risks to the patient undergoing surgery. These exams are billable to Medicare and most insurance companies.

Timing of the H&P is important. Medicare’s global period for major surgery includes 90 days of postoperative care, as well as one day of preoperative care. H&Ps performed by the surgeon on the day of or the day prior to a major surgery will fall into the global period and not receive separate reimbursement.