# Counsel service within global period of procedure



## jaud63 (Sep 24, 2009)

Please let me know if this can be coded and if there is specific information somewhere to justify the service.

Example-Patient has surgery for breast lumpectomy with diagnosis of breast lump. The patient returns for a follow-up visit within the global period of the surgery (90 days) for counseling regarding treatment options for breast cancer found on the pathology report of the biopsy. The f/u visit includes the modifier 24. The f/u visit is either with the surgeon or the surgeons associate.

Codes     DOS   1/1/2008 Surgery    CPT-19101  Dx  611.72   
             DOS   1/7/2008  E/M CPT  99215-24 (Time-based)   Dx  174.9  

Thanks


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## marsha.russell (Sep 24, 2009)

our doc do not charge this f/u visit and actually you can not charge it because it is in the global period.


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## lindacoder (Sep 28, 2009)

If the diagnosis of breast cancer was not made before the surgery then you can and should charge for the post op visit with a 24 modifier - having the surgeon dictate time based is the best route as they usually do a quick physical exam and then discuss and answer questions regarding the diagnosis and treatment. Typically in our office at least 30 minutes is spent with the patient discussing the options for further treatment.


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## mitchellde (Sep 28, 2009)

I agree with Marsha, this is totally part of the global, the dx of the breast cancer is related to the surgery as that is what came out of the symptom.  To bill this as a visit with a 24 is really not correct.


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## LLovett (Sep 28, 2009)

I agree this is part of the global and it is not appropriate to use the 24 modifier.

I have recently had a few coders use the term "normal" when describing the global period, and that even though 24 says unrelated they use it for services that are beyond what is "normally" provided during post op. I disagree with this based on CMS guidelines but I would love to see supporting documention from other sources that support billing these services with the 24.

Laura, CPC, CEMC


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## nc_coder (Sep 28, 2009)

I agree that you do not bill for the consultation after the procedure to diagnose.  I recently attended a General Surgery seminar put on by McVey and Associates.  The presenter actually made this particular situation very clear.  The E/M service after the procedure to diagnose and before the procedure to treat is part of the global period.


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## tanyaharberts (Sep 30, 2009)

I used to think this was included in the global, but I just read in the Oct '09 Coding Edge (p. 45) that an E/M visit within the global period of a breast biopsy that reveals a malignancy is billable with a 24 modifier.  

This article states, "The purpose of the E/M was to provide care and counseling for the underlying condition (malignancy) and is not part of the normal recovery phase of the procedure."

It lists (Medicare Claims Processing Manual, pub. 100-04, chap. 12, sec. 40.1.B) indicates the visit was unrelated to postoperative care within the global period.

I looked up that reference and found:
B. Services Not Included in the Global Surgical Package
-Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery

I understand from this that the 'underlying condition' or an 'added course of treatment' is the key.  Does anyone else have references to the contrary?


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## LLovett (Sep 30, 2009)

I guess I have a hard time saying it is unrelated when the surgery is what lead to the diagnosis being made. 

To me unrelated is just that, it has nothing to do with the procedure. This wasn't an underlying condition this was found as a direct result of the procedure. 

Now I completely agree that the treatment related to the cancer would be unrelated to the surgery and it would be billable. But I still feel that the visit to tell them they have cancer and go over options is inclusive to the global period in this situation.

Just my opinion,

Laura, CPC, CEMC


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## FTessaBartels (Sep 30, 2009)

*Modifier 24 Unrelated*

Well, it's not often that I disagree with Laura, but on careful reading of the Medicare guidelines I feel this WOULD be a separately billable E/M (with -24 modifier).

The key is as tprescott quoted:
B. Services Not Included in the Global Surgical Package
-Treatment for the underlying condition or an added course of treatment which is not part of *normal recovery from surgery* (emphasis added by FTB)

This would *not* be part of the normal recovery from this surgery. Normal recovery follow-up would be looking at signs of infection, adquate pain control, suture removal etc. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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