ED Coding and Reimbursement Alert

For many emergency department coders, "What comprises a global surgical package?" is the $64,000 question. Understanding what is and isn't included in the payment for a primary procedure can make a tremendous difference in the bottom line.
 
In CPT 2002, the AMA defines the components of a surgical package more clearly. Within the notes explaining surgical guidelines in the 2002 manual (page 43 of the Professional Edition), CPT outlines which services are always covered within the global service:

 

local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
 

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 dictating operative notes, talking with the family and other physicians
 

writing orders
 

evaluating the patient in the postanesthesia recovery area
 

typical postoperative follow-up care.

"This information is very helpful," says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Lansdale, Pa., that specializes in practice management consulting with a focus on physician compliance, coding, billing, education and reimbursement. "Chapter 22, Section 22-2d and 22-3 of the Medicare Part B Reference Manual also has a great explanation that can help clarify the issue for coders."
 
Global surgical periods cover a range of 0 to 90 days surrounding the service, depending on the type of procedure performed. Fees for the procedure then include routine care (both before and afterward) related to service. Complications or unrelated services during the postoperative period, however, are considered exceptions, and physicians may bill for them separately.
 
According to Falbo, this is an important distinction for emergency department coders to understand. "There are occasions when an ED physician may see a patient during a global period and the services may be separately payable. If the coder is unclear about what falls outside the surgical package, a legitimate opportunity for reimbursement might be lost." In addition, diagnostic services (e.g., x-rays to determine whether the patient fractured a bone) are not considered part of the global package and may be billed separately.
 
In some instances, the ED physician may have an opportunity to report a visit code in addition to a treatment code. When this occurs, it is likely that either modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) or -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) may be appended to the ED visit code.
 
"Modifier -24 would be used, for instance, if the ED physician saw the patient twice within a short period of time," Falbo says. "The first encounter may have included a treatment covered by a global period (e.g., 10060*, incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single, with a global period of 10 days). A week later, the same physician saw the patient for a high fever and severe headache. This second visit would be assigned the appropriate level of ED service code, appended with the -24 modifier to let the insurer know that the visit during the postoperative period was unrelated."
 
In another case, a patient may return to the ED after experiencing a complication resulting from the original treatment perhaps the sutures came loose from a wound that had been repaired five days earlier (e.g., 13100, repair, complex, trunk; 1.1 cm to 2.5 cm, has a global period of 10 days). If the same physician saw the patient both times, the repair would have been reported during the first visit. Because the problem with the sutures is considered an unusual circumstance and not routine, the second visit would be coded with the ED visit code and modifier -24.
 
On other occasions, the ED physician may evaluate the patient for multiple conditions on the same day that he or she provided a specific treatment. For instance, an elderly patient may have fallen down a flight of stairs. The ED physician may treat the patient for a simple fractured tibia (e.g., 27530, closed treatment of tibial fracture, proximal [plateau] without manipulation), which carries a global period of 90 days. At the same time, the doctor most likely will also evaluate the patient for a head injury or neurological disorder that may have caused the fall. This evaluation, considered significant and separate from the evaluation of the broken lower leg, would be reported with the proper ED visit code (e.g., 99283) with modifier -25.

CPT also contains a category of codes that are excluded from the concept of global surgical packages. These exceptions are classified as "starred" procedures and are identified by an asterisk next to the code in the CPT manual (e.g., 10120*, incision and removal of foreign body, subcutaneous tissues; simple). When reporting these procedures, coders may also assign codes for other services that would be considered part of the global package for non-starred procedures.
 
For instance, a patient may require a digital block when a starred procedure is performed. Although the block would typically be bundled into a global surgical package, it may be separately reported with a starred-procedure code. A patient presents with a laceration to the tip of the finger from a fall onto pavement. After an assessment of the patient and other possible injuries secondary to the fall, the ED physician determines that suturing of the finger laceration is necessary (12001*, simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less). Due to the nature of the laceration, the physician determines that a digital block is necessary as an anesthetic (64450*, injection, anesthetic agent; other peripheral nerve or branch). Because of the starred-procedure rule, the ED visit (e.g., 99282, emergency department visit for the evaluation and management of a patient, which requires an expanded problem focused history and examination, and medical decision making of low complexity), the laceration repair and the digital block may all be reported. Since the laceration repair has the highest relative value unit (RVU) at 1.70 work RVUs, it would be reported in the primary position without a modifier. The digital block (1.27 work RVUs) would be reported with modifier -51 (multiple procedures) attached, while the E/M service (99282 carries 0.55 work RVUs) would have modifier -25 attached.

Professional coders with experience in other areas of E/M coding may be familiar with a special code established by CPT for new patients when a starred procedure is the primary reason for the encounter (99025, initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit). When this situation occurs, both 99025 and the starred-procedure code are reported, with no modifiers.
 
Code 99025, however, does not apply to the emergency setting because an ED site of service does not recognize either new or established patient designations.