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Readmission while in global period

Debra Posted Mon 17th of February, 2020 08:54:45 AM
Hoping you can help me with the following scenario that I am receiving a denial for. Patient has a Medicare Advantage plan. Surgeon performs total right hip arthroplasty on 10/30/19. Patient is discharged from the hospital, but is readmitted by same surgeon on 11/24 @ 0040 for fever due to either COPD with atelectasis vs abscess/hematoma in surgical region and starts her on IV antibiotics. On the same day @12:46 he rechecks her, now pulling in diagnoses of GERD, hyperlipidemia, anxiety, cellulitis of right hip region and hypothyroidism (since she is inpatient). I have two questions at this point: I know per MC guidelines that I can only bill one E/M visit per day since it’s the same physician, but because the patient is still in a global period do the other diagnoses make this separate and identifiable? I billed this as an initial hospital code 99223 with a 24 modifier? This is the first denial. Care is continued on 11/25 as he rechecks her, I billed a subsequent E/M code 99231-24. Surgery is recommended to evacuate the hematoma, but the patient refuses and asks to be discharged. On 12/4 the patient is readmitted by the hospitalist, my surgeon sees her again and surgery is performed for the hematoma on 12/5. I have used code 99231 with modifiers 24 and 57. My procedure code is 26990 with a -78 modifier. They are denying the subsequent hospital code and only paying me for the surgery. This was the second denial. I used the -57 originally due to billing this again with separate diagnoses from the original surgery or is all of this incorrect? They are however paying for the second day hospital visit and the surgery. I appreciate any help you can give me! I code for a private orthopedic practice so I don't come across these scenarios very often.
SuperCoder Answered Tue 18th of February, 2020 04:13:13 AM

Hello Susquehanna Valley,

Thank you for your question.

 

Please find the below response(s) for your provided documentation.

 

For DOS 11/24, the patient was readmitted for fever due to either COPD with atelectasis vs abscess/hematoma in surgical region. Kindly specify the primary diagnosis for admission.

(The possible denial reason for 11/24 visit can be the primary diagnosis assigned to the visit).

 

For DOS 11/25, the care was continued and surgery for recommended to evacuate the hematoma, but patient refused the surgery and got discharged (it may also be related to services performed on 11/24)

 

For DOS 12/4, what was the reason for admission and what services did your surgeon performed?

(As per the provided documentation, it is indicating that the visit (12/4) was for hematoma evacuation procedure).

 

For DOS 12/5, code 99231 is denied because hematoma at the surgical site is a complication of the original surgery done on 10/30; hence, it will be considered inclusive in the global period of THA.

 

Do let us know in case of any further query.

 

Hope that helps!

Thanks

Debra Posted Tue 18th of February, 2020 09:41:33 AM
Thank you for your rapid response. For the day of admission on 11/24 I used codes R50.9, J98.11, and M97.01XA, in that order, as my first listed diagnoses along with her other comorbid conditions due to being inpatient. I am questioning why they would deny that day, but then pay for the subsequent visit the next day where he then determines cellulitis and the hematoma as the cause of her fever?
SuperCoder Answered Wed 19th of February, 2020 05:51:44 AM

Hello Susquehanna Valley,

Thank you for your additional information.

 

Could you please provide us with the reason of denial/or explanation of benefit (EOB) document received from insurance for DOS 11/24, 12/4 and 12/5. This document will help us understand the possible reasons for denials. Kindly share the EOB on customerservice@supercoder.com

 

Thanks

Debra Posted Wed 19th of February, 2020 13:14:28 PM
My apologies. Denied due to : the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Thank you!
SuperCoder Answered Thu 20th of February, 2020 06:00:34 AM

Hello Susquehanna Valley,

Thank you for providing the information.

 

As per your payer the services have already been adjudicated. It seems that the service (for DOS 11/24) had been paid and your payer has recouped the overpayment probably made in the earlier submitted claims with the current claim.

 

It is advised to kindly get in touch with your respective payer for more clarity.

 

Thanks

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