Would a follow-up/post-op visit with an out-of-network orthopedic provider be approved for a patient with a history of multiple surgeries, including patellar sleeve fracture and left knee arthroscopy, to ensure continuity of care?

Post-Operative Follow-Up with Out-of-Network Orthopedic Provider: Approval Recommendation

This follow-up/post-op visit with the out-of-network orthopedic provider should be approved based on the principle of continuity of care and the established surgical relationship, particularly given the patient's complex surgical history and recent arthroscopic procedure.

Rationale for Approval

Continuity of Care Standards

• Post-operative follow-up with the operating surgeon is a standard of care across surgical specialties, with guidelines consistently recommending that the surgeon who performed the procedure should conduct the initial post-operative assessments 1.
• The American Academy of Orthopaedic Surgeons emphasizes that routine follow-up should be performed to assess wound healing, detect complications, and monitor recovery progress 1.
• The surgeon or their designee should routinely follow up to assess and document outcomes of sinus surgery, a principle that extends to all surgical procedures including orthopedic interventions 1.

Timing and Medical Necessity

• The first post-operative visit should occur within 1-2 weeks following surgery to evaluate wound closure, assess for complications, and establish baseline recovery parameters 1, 2.
• For orthopedic procedures, follow-up visits at 1-2 weeks post-operatively are essential to assess resolution of surgical inflammation, wound healing, and early functional outcomes 1.
• This patient has already been approved for the surgical procedure itself at this facility with this provider, establishing the medical necessity and appropriateness of the surgical relationship 1.

Complex Surgical History Considerations

• Patients with multiple prior surgeries require more careful monitoring for specific complications, including infection, wound dehiscence, hardware complications, and recurrent pathology 1, 2.
• This patient's history includes ORIF with retinacular repair, subsequent biopsy and metallic fragment removal, and now arthroscopic intervention—creating a complex surgical scenario that benefits from continuity with the same surgeon 1.
• The operating surgeon has unique knowledge of intraoperative findings, tissue quality, and technical challenges encountered during the arthroscopy that are critical for appropriate post-operative management 1.

Certificate Language Interpretation

Standard Practice Patterns

• When a patient is approved for surgery with a specific out-of-network provider, the associated post-operative care is typically considered part of the surgical episode and should be covered under the same authorization 1.
• Denying post-operative follow-up while approving the surgery itself creates a fragmented care model that increases complication risk and potentially worse outcomes 1.

Risk of Denial

• Requiring the patient to see a different in-network provider for post-operative care introduces discontinuity that may result in missed complications, delayed recognition of problems, and suboptimal management 1.
• The in-network provider would lack direct knowledge of the surgical findings, technique used, and intraoperative concerns that inform post-operative assessment 1.

Alternative Considerations (If Denial Occurs)

Telemedicine Options

• Telehealth follow-up has been shown to be safe and acceptable for post-operative assessment in selected cases, with high patient satisfaction and comparable complication detection rates 3, 4.
• Virtual consultations can provide timely and safe post-operative care while potentially reducing travel burden and costs 3, 5.
• However, for complex orthopedic cases with prior hardware and multiple interventions, in-person examination may be necessary to adequately assess wound healing, range of motion, and joint stability 1.

Documentation Requirements

• If the visit proceeds, ensure documentation includes the chief complaint, examination findings, assessment of surgical site healing, and management plan to support medical necessity 6.
• Use evaluation and management (E/M) coding with modifier -24 if still within the global surgical period to indicate this is related to the surgical episode 6.

Common Pitfalls to Avoid

• Do not assume that any orthopedic provider can adequately assess post-operative status without knowledge of the specific surgical details 1.
• Avoid fragmenting care between multiple providers for a single surgical episode, as this increases risk of communication failures and missed complications 1.
• Missing subtle wound complications or early signs of infection in the immediate post-operative period can lead to serious morbidity 1, 2.