A trauma surgeon managing postoperative cardiac arrhythmias, titrating anticoagulation, and directing intensive care unit resuscitation may perform services that are separately billable if they are documented and coded in accordance with current guidelines.
That’s according to an expert panel summary from the American Association for the Surgery of Trauma (AAST), published in Trauma Surgery & Acute Care Open. The authors — five acute care surgeons from academic, military, and community settings — describe documentation and coding as areas in which many surgeons receive limited formal training.
The review summarizes Centers for Medicare & Medicaid Services (CMS) requirements related to billing in several common scenarios, including care delivered during global periods, split/shared visits with advanced practice providers, cosurgery arrangements, interpretation of imaging, and time-based critical care services delivered across multiple hospital locations.
The authors also highlight the 2021 transition to medical decision-making-based evaluation and management coding. Under this framework, credit is assigned based on documented elements including the complexity of problems addressed, data reviewed, and risk. The paper notes that auto-populated laboratory values or imaging reports alone are not sufficient; clinicians must document their review and interpretation of these data.
Modifier use is another focus. For example, modifier 22 may be applied when procedural work is substantially greater than typical, but it requires detailed documentation and is associated with higher denial rates. The authors emphasize that it should be used selectively and supported by clear justification.
The paper also outlines documentation requirements for billing with trainees and advanced practice providers, as well as the use of modifiers for services unrelated to a procedure during a global period. In addition, it reviews critical care billing rules, including time-based requirements and the ability to count qualifying care delivered across multiple settings.
In their conclusion, the authors state that improving familiarity with coding principles can help surgeons better align documentation with current policy standards and more accurately capture reimbursement for the care they provide. They also emphasize the importance of collaboration with institutional billing and coding professionals.
The authors declared no competing interests.
Source: Trauma Surgery & Acute Care Open
