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 [...]