How Do I Get Paid: Medicare, Medicaid, Insurance, Billing Pearls

Abstract

This chapter provides a basic overlook of medical billing in surgery, including definitions and a few routinely encountered surgical scenarios. Medical billing is a complex piece of a career in surgery that can have a huge impact on earnings and reimbursement. Unfortunately, due to its complexity, many surgeons overlook the value of understanding billing, and few residents gain experience in this area. A simple comprehension of the process can improve communication with billers and insurances, ultimately leading to a more satisfying and fruitful practice.

Appendix

Frequently used modifiers for surgical billing

Code	Use	Example
-24	For evaluation and management of a problem unrelated to the primary diagnosis completed within the global period	A patient who has previously undergone a hernia repair returns within the global period with complaint of biliary colic
-25	For evaluation and management of a problem unrelated to the reason for a procedure completed on the same day as the procedure	A patient presents for removal of a skin lesion with a new onset right groin pain
-50	To indicate bilaterality	A right inguinal hernia repair completed on the same day as a left hernia repair (only one CPT will carry this modifier)
-53	To indicate the procedure was aborted prior to completion	A patient develops an allergic reaction to local anesthetic requiring the planned hernia repair be aborted. An operative note must be submitted indicating why the procedure was aborted and at what step.
-57	For evaluation and management of the primary problem if originally diagnosed on the same day as a procedure	The workup of a patient in the Emergency Department who later goes to the OR for an appendectomy
-58	For a planned take back or staged procedure when this procedure is completed within the global period	A mastectomy that takes place within the global period of previously completed open breast biopsy
-59	To indicate a separate and unrelated procedure that was completed on the same day as the primary procedure	A port-a-cath placement completed at the same time as PEG placement
-78	To indicate an unplanned return to the OR related to the primary procedure	A patient develops fascial dehiscence after a laparotomy requiring return to the OR for exploration and fascial closure
-79	For an unplanned return to the OR unrelated to the original procedure	A patient who underwent inguinal hernia repair develops appendicitis within the global period