ED Coding and Reimbursement Alert

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 [...]