ED Coding and Reimbursement Alert

The Global Surgical Package Unwrapped

Published on Sat Feb 01, 2003

Questions about the global surgical package keep coming in from emergency department coders: May I bill a starred procedure with an E/M code? How many global days does a laceration have? Is an infected wound included in the global surgical package?

Here's a comprehensive, straightforward answer to your global surgical inquiries.

For starters, the global surgery rules prohibit a separate reporting of an E/M service when it is part of the normal preparation for surgery or the postprocedure recovery process, says James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa.

CPT: Starred versus Nonstarred Procedures

Every time you have a CPT surgical code without a star, CPT guidelines state that the following services are always bundled into the code:

Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history or physical). Note that you can still separately report an E/M that occurred before the decision to perform surgery, Blakeman says.

Typical postoperative follow-up care. Take an infected wound; that doesn't qualify as typical, Blakeman says. You can report care for it separately.

Immediate postoperative care, including dictating operative notes, and talking with the family and other physicians

Local infiltration, metacarpal/metatarsal digital block or topical anesthesia.

Evaluating the patient in postanesthesia recovery area.

Writing orders.

Follow-up care on diagnostic (e.g., endoscopy) and therapeutic procedures is only included for the recovery of the procedure and not the treatment of the underlying condition, Blakeman adds.

Starred procedures, codes followed by *, do not invoke the same global surgery rules, Blakeman says. Follow these rules for starred procedures:

Report postoperative E/M services separately, Blakeman suggests.

If the starred procedure is the "major service," report 99025 instead of an E/M code for additional services. In other words, Blakeman says, if you haven't done a "real" E/M service, use 99025 (Initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit).

Don't report a separate E/M code if, for example, your documentation doesn't report anything extensive beyond the one procedure. The rule applies to all codes in the surgical section (10040-69979)

Don't include local infiltration, digital block or topical anesthesia in the procedure code, Blakeman adds.

Report a separately identifiable E/M, supported by chart documentation. Don't forget modifier -25 on the E/M codes.
Medicare: Minor versus Major

A common mistake many coders make is to assume that Medicare pays according to the starred versus nonstarred distinction.

But Medicare does not follow the CPTstarred and surgical package concepts, Blakeman says. Medicare distinguishes instead between "minor" and "major" procedures in order to "determine how much content must be contained in the E/M service before it can be reported in addition to the procedure." In other words, Medicare has its own rules for global surgical packages, so listen up.

Medicare ascribes "minor" and "major" to CPT codes as a way to define their global surgical packages. Minor and major packages are defined according to days. All Medicare procedures subject to global payment policies have a global period between 0 and 90 days, Blakeman says. The policies apply primarily to the codes between 10040 and 69979.

A minor procedure includes the procedure and postoperative care from 0 to 10 days after the surgery. Bundled into minor procedures are E/M services, unless the E/M is a significant and separately identifiable procedure. Minor services do not include postoperative care by another physician. Refer to the global policy description below for additional inclusions.

A major procedure includes the procedure and postoperative care forup to 90 days (and "by carrier discretion"), Blakeman says. Major procedures have the same E/M rules but do include in payment the postoperative care by another physician, Blakeman says. Refer to the global policy description below for additional inclusions.

If the procedure has no global period, you can bill the E/M service with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Paula W. Schalen, CPC, at Pottstown Healthcare Corporation. Otherwise, global surgery period rules apply.
Medicare's Global Payment Policy

For those procedures subject to Medicare's global payment policy, payment includes:

Preoperative visits related to the surgery. The same concept applies here as it did to pre-op visits for CPT, Blakeman says. The payment includes pre-op visits after the decision to perform surgery, he says, so the initial E/M is not bundled into preoperative visits.

Complications following surgery not requiring re-operations during the post-op global period.

Post-op pain management by the surgeon.

Supplies and related services (dressing changes, local incisional care, routine urinary catheters, and peripheral IV lines, etc.).

The Medicare payment does not include:

Evaluation to determine the need for surgery.

Services of other physicians to whom care is transferred.

Visits unrelated to the diagnosis that required surgery.

Treatment for the underlying condition.

Diagnostic tests, including radiologic procedures.

Post-op critical care unrelated to the surgery.

Use modifier -25 to report an E/M service beyond the usual preoperative or postoperative care associated with the procedure, Blakeman says (see box for more details). For emergency E/M services, performed to report the need for major surgery, use -57 (Decision for surgery) instead of modifier -25, he adds.