EM Coding Alert

Receive separate payment when conditions allow.

Knowing the number of post-operative days of a surgical package, tells you whether or not you might get paid for an E/M encounter that happens within days of a procedure. If you don’t understand global period billing rules, you could be leaving money on the table or setting your provider up for a denial. 

Get a grip on how the periods impact your E/M coding with this rundown of the different types.

Break Down the 3 Types of Global Periods 

While there are several types of global periods, there are three that most of the codes you use will fall under: 0-day, 10-day, and 90-day. 

0-day: Zero-day global periods involve procedure codes with a global surgery indicator of “000.”  A 0-day global period applies to procedures like endoscopies and other minor surgeries, such as joint injections. Get familiar with the following points about 0-day procedures:

• There is no pre-operative period
• There is also no post-operative period
• Any visit on the day of the procedure is generally not billed as a separate service.

10-day: A 10-day global period involves procedure codes with a global surgery indicator of “010.” These global periods consist of 11 actual days, which include the day of the surgery and 10 days following the day of surgery. No pre-operative period is included.

You’ll find that many minor surgical procedures carry a 10-day global period.  Some examples are casting/splinting, laceration repair, and wound debridement.

90-day: The 90-day period will encompass procedure codes with a global surgery indicator of “090.” The total global period is actually 92 days. You count one day before the procedure, the day of the surgery, and the 90 days of post-operative care immediately following the surgery. 

You’ll find that major surgical procedures carry a 90-day global period. Examples of major procedures are fracture care, tumor resections, and spinal care.

Pointer: An E/M service your provider performs the day of the procedure is generally not payable as a separate service. However, for procedures with a 90-day global period, if the decision for surgery is determined by an E/M service performed on the same day or the day before an unscheduled surgery, you should attach modifier 57 (Decision for surgery) to the E/M code. This will allow you to receive separate payment for the E/M work in addition to the procedure.

Brush Up on When You Can’t Bill an E/M Code Separately

While there are times you can separately report an E/M code within a day or so of a surgical procedure, there are times you shouldn’t. For example, you cannot bill a separate E/M code related to the procedure on the day before or on the same day as minor procedures, or the day of surgery for major procedures if your physician made the decision for surgery at a previous encounter. Typically, this applies when a patient comes back for a pre-op history and physical (H&P), which would not be billable with an E/M code.

“Another situation would be when services are normally part of a surgical procedure,” says Sharon Morehouse, MPA, IA, owner of Beyond Basics Medical Billing Service, LLC of Honeoye Falls, N.Y.  Any E/M procedure or service provided during the post-operative period that is related to the recovery from the surgery, including pain management, cannot be billed separately, continues Morehouse.

Example: Your provider removed a benign lesion from a patient’s face. The lesion removal required sutures. Five days after surgery, the patient notices irritation and redness around the wound site and requires an evaluation to determine if the site is infected. Your physician prescribes antibiotics for a minor infection. 

“This visit would be considered related to the actual procedure performed, and would fall under the guidelines of post-op,” Morehouse explains. “An additional E/M code could not be billed for these services.” 

Recognize 4 Other Indicators With No Specific Time Periods

Some codes do not have specific time periods for post-op care attached to them; that is, they do not fall under the normal 0-day, 10-day, or 90-day global period designations. 

Exception #1: Codes with the “YYY” designation are contractor-priced codes. That means your payer can determine the global period. YYY usually applies to unlisted procedures, and the global period a payer assigns will depend on the type of unlisted service.

Tip: “The global period for these codes will be 0, 10, or 90 days,” according to the CMS Global Surgery Fact Sheet dated August 2013. “Note: Not all contractor-priced codes have a ‘YYY’ global surgical indicator. Sometimes the global period is specified as 000, 010, or 090.” To learn more, take a look at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf.

Exception #2: The “ZZZ” designation applies to add-on codes that you must bill with another service. There is no post-operative work included in the Medicare Physician Fee Schedule (MPFS) payment for the “ZZZ” codes. Payment is made for both the primary and the add-on codes. The global period applies to the primary code.

Exception #3: The “MMM” indicator describes maternity codes. In these cases, the usual global period rules do not apply. CPT® guidelines explain that the services normally provided in uncomplicated maternity cases include antepartum care, delivery, and postpartum care. Essentially, all services related to an uncomplicated birth are bundled into the surgical package for the delivery services. You’ll find that all delivery codes in the 59400-59525 and 59610-59622 ranges carry a “MMM” global period.

Exception #4: When you see an “XXX” in the fee schedule’s GLOB DAYS column, the global concept does not apply to the code. In other words, services and procedures with an “XXX” global period indicator include only the service or procedure itself, along with any (minor) inherent E/M component. 

Example: All A codes (A0021-A9999), as well as donor lung preparation services (32855-32856) have an “XXX” global period.

Beware: Medicare lists the global periods in its Fee Schedule, but you should ask private payers for their global periods in writing because they may differ from Medicare’s policy.