Interpretation of Rule G: Delegation of Post-operative care

Standard, uncomplicated post-operative after-care is incorporated for four weeks in the global fee of any surgery unless otherwise specified.

The exception to the rule is a complication or exacerbation of an underlying co-morbidity, or other diseases that are present (e.g. post-operative pneumonia, pyrexia, wound complications, etc.)

If the STANDARD after-care is delegated to any other registered health professional and not concluded by the surgeon, it shall be his/her own accountability to arrange for the service to be rendered without extra charge.

However, it must be stated that if a physician/cardiologist codes for after-care because of cardiac problems, during the global period after surgery, that visit is not to be considered part of normal after-care and therefore an exception to the global period as stated by Rule G. The Medical Scheme, and not the referring doctor, is then held accountable for receipt of the claim. It is important to add the appropriate ICD-10 codes to the claim to indicate the reason why the patient was seen by the physician/cardiologist

“Rule G” as appearing in the SAMA MDCM (Medical Doctor’s Coding Manual):

Rule G

Post-operative care:
(a) Unless otherwise stated, the units in respect of an operation or procedure shall include normal aftercare for a period not exceeding FOUR weeks (aftercare is excluded from pure diagnostic procedures during which no therapeutic procedures were performed).

(b) If the normal aftercare is delegated to any other registered healthcare professional and not completed by the surgeon, it shall be his/her own responsibility to arrange for the service to be rendered without extra codes.

(c) When post-operative care/treatment of a prolonged or specialised nature is required, the benefit, as may be agreed upon between the surgeon and the scheme or the patient (in case of a private account), may be used.

(d) Normal aftercare refers to an uncomplicated post-operative period not requiring any further incisions.

(e) A complication or exacerbation of an underlying co-morbidity that requires care other than normal aftercare for the particular operation, will qualify for a follow-up consultation item. Treatment of conditions such as post-operative pneumonia, pyrexia, wound complications, prolonged ileus (>5 days), DVT, etc, is not considered as part of normal aftercare

M0006

Visiting specialists performing procedures: Where specialists visit smaller centres to perform procedures, units for these particular procedures are exclusive of aftercare. The referring medical doctor will then be entitled to subsequent hospital visits for aftercare. If the referring doctor is not available, the specialist shall, on consultation with the patient, choose an appropriate locum tenens. Both the surgeon and the doctor who handled the aftercare, must in such instances quote modifier 0006 with the particular items which they use

*Modifier 0006 is the exception where it indicates that the aftercare is done by the referring doctor after the procedure was done by a specialist in a smaller centre - thus the specialist travelled to the smaller centre, did the procedure and the patient’s GP is looking after the patient during the post-operative care.

Rule G is in place so that the same service is not charged for twice. For example, a surgeon is remunerated for time to care for patients post-operatively and into their recovery period post discharge. In the event of such care being delegated to a colleague, this would then levy an additional charge. Essentially the patient or medical scheme will be paying twice for the same service. Rule G has been incorporated to avoid instances like these.

The South African Society of Anaesthesiologists have recommended the following:

1. In case of an uncomplicated surgical procedure and patient, the surgeon is (in terms of coding rules) remunerated for the care of the patient. Any funder (patient funders included) would be within their right to not pay additional fees to other practitioners for this expected and standard care.

2. In the case of a complicated patient or procedure that is complicated, additional ICD codes would be appropriate to the patient and must be reported by any professional delivering care additional to the surgeon’s post-operative care. The failure to report these codes give no insight into a funder as to why a patient required more than expected post-operative care. The primary surgical code should still appear on the colleague’s invoice as well as applicable additional codes. The concerns are as follows:

a. Many schemes expect coding of all parties to match and remain consistent and will not reimburse outside of this.
b. Many schemes require the hospital case manager to submit additional ICD 10 codes who are often ill equipped to apply such coding. They have no insight into the patient and their care and do not ensure the coding is correct resulting in invoices being rejected from the practitioners.
c. Certain procedures and inherently complicated with more intensive post-operative care requirements outside of the surgeon’s domain of care. /such instances may be poorly catered for with respect to specific ICD 10 coding.

3. In the case of anaesthetic consultations and anaesthetic required care such as pain management (outside the domain of the surgeon e.g. PCA, epidural care) in the post-operative patient, this is specifically excluded for in Rule G and may be reported using the same ICD 10 codes as for surgical procedure.

4. Rule G applies to patients admitted to High Care or ICU procedurally. Clearly these patients are more likely to have other co-morbidities and may require multi-disciplinary care within the prescripts of Rule G. In terms of ICU coding:

• Doctors involved need to decide who the Primary medical doctor is. This can be indicated on the ICU chart so that all other doctors involved can communicate with him/her
• A decision needs to be made on the Category of the patient and all involved medical doctors should use the appropriate codes. It would be better for the Category of the patient to also be indicated on the chart by the Primary medical doctor for all to see.
• The correct, appropriate, ICD-10 codes need to be used by all treating doctors and this may need to be changed after admission and hospital administration staff encouraged to update these codes daily.
• When billing:

+  Only one doctor can code item 1204 and the rest item 0190. Item 1204   should only be used for Category 1 patients. 

+ Category 2 patients, where the Primary medical doctor uses either items 1205, 1206 or 1207 – all other medical doctors can only use item 0109. 

+  One should only use code item 1210 when a patient is a category 3 or a category 2 with multi-organ failure and on subsequent days. On the first day the Primary medical doctor uses item 1208 and all supporting doctors’ use item 1209. In other words one can use item 1210 if the Primary medical doctor is also using item 1210.

*** Please note that the specialist of another discipline must obtain specific authorisation for the hospital service and cannot simply ride on the specific specialist for e.g. Orthopaedic procedural authorisation.

Many Schemes now insist on separate authorisation per clinical and medical necessity for co-attending multi-disciplinary team; physiotherapist, dietician, OT, specialised radiology all require separate PAR.

The global fee as appearing in the CPT (Current Procedural Terminology) is defined as:

CPT Global Surgical Package Definition

Services provided by the surgeon to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. In defining the specific services "included" in a given CPT surgical code, the following services are always included in addition to the operation per se:

• local infiltration, metacarpal/metatarsal/digital block or topical anaesthesia;

• subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical);

• immediate postoperative care, including making operative notes, talking to family and other surgeons, writing orders;

• immediate postoperative care, including making operative notes, talking to family and other surgeons, writing orders;

• typical postoperative follow-up care.

• dressing changes, local incisional care

• removal of operative packs, sutures, staples, lines, wires, tubes, drains, casts and splints

• insertion, removal and irrigation of urinary catheters

• routine peripheral intravenous lines and nasogastric and rectal tubes

• changes and removal of tracheostomy tubes.

Follow-up Care for Diagnostic Procedures includes only care related to recovery from the diagnostic procedure itself (e.g. endoscopy). Care of the condition for which the diagnostic procedure was performed or other concomitant conditions not included & may be listed separately.

Follow-up Care for Therapeutic Surgical Procedures includes only that care which is usually a part of the surgical service and is included for a specified number of days referred to as the global period. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported, specifically identified by unique ICD codes and specific modifiers.

If the complication requires the patient return to theatre, these services will be paid separately from the global surgery allocation. The theatre or operating room includes cardiac catheterisation suite, radiological interventional suite and endoscopy suite. It does not include the patient room, minor treatment room, recovery room or ICU (unless the patient’s condition was so critical that there would be insufficient time or logistic reasons precluding transportation to an operating room).

Conclusion:

Again, what is of extreme importance is that, where a multi-disciplinary approach is being followed, each doctor should code in primary position the ICD-10 code(s) that describes his/her role in the treatment of the patient, without giving the funder the idea that there was a duplication of services or that more than one doctor is treating the patient for the same condition.

Should you have any coding queries you can contact us on: coding@samedical.org

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