EM Coding Alert

Surgical packages may be a glass half full/glass half empty situation.

During his HEALTHCON 2024 session, “Risk and Reward with General Surgery Coding,” Christopher Chandler, MHA, MBA, CPC, CGSC, aimed to help coders and practitioners communicate clearly about what procedures and services should and should not be billed separately.

Continue reading for a better understanding of when it’s appropriate to bill for services and procedures and when it may result in a claim denial or underpayment.

Use Your Resources

“There is a lot of potential for unbundling, so the more you know about the guidelines, the better and the more you can relate to your physicians, the more it will help you,” said Chandler.

He urged the audience to review the National Correct Coding Initiative (NCCI) Policy Manual until they are comfortable with it as this will help to correctly code procedures and help to better understand what is included in each surgical package. “You should also familiarize yourself with the resources available from the American College of Surgeons. They are the authority on general surgery. They release coding guidelines and clearer explanations,” he added.

Gain Clarity on Surgical Packages

In the CPT^® manual, for surgical packages, “you need to add modifier 57 [decision for surgery] to have an [evaluation and management] E/M service separately reported the same day or the day before any scheduled major surgery. If you don’t add modifier 57, any services performed on those days would not be considered part of the global package and could be denied,” said Chandler. By adding that modifier on there, you are telling the payer that this is not the preoperative history and physical, and it should be reported separately because this is the effort made to determine that surgery is the correct care.

He warned that Medicare will not pay for anything that it considers already part of the global package. You should only bill separately for complications if the patient must make an additional trip to the operating room (OR), reporting those services with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period). However, if a patient is being treated only for post-op complications, then it’s still billed as part of the surgical package, not separately. “This is why a lot of surgeons struggle with Medicare’s definition of a surgical package. Even if they are doing a ton of extra work than what is typical of post-operative care, they won’t be paid separately for it,” he said. An audience member did point out, however, that the same amount is still paid to the surgeon whether they did extra work on complications or had a smooth surgery, so this policy could be seen as a positive thing since most surgeries don’t see complications.

He went on to discuss Inherent Services. “These are the services that are not included in the definition of the CPT^® code, but they are included.” Some examples of inherent services include:

• Control of bleeding
• Iatrogenic injuries (a surgical error or unintentional injury during the procedure)
• Biopsies
• Incision/Closure

The key to iatrogenic injuries is to make sure the physician is aware you can’t bill for damages or injuries that they created themselves during the surgery. Keep in mind however, that you should still be sure to add all necessary diagnosis and CPT^® codes on the claim, so the payer has a better picture of what occurred in the operating room.

Know When to Use Modifiers

Chandler acknowledged, “I’ve had people ask me ‘when can I bill things separately?’ You can bill separately when your documentation supports one of the following situations:”

• Different session (return to the OR)
• Different procedure or surgery
• Different site or organ system, separate incision/excision
• Separate lesion
• Separate injury (or area of extensive injuries)

“I like to be consistent. If Medicare is accepting modifier 59 [distinct procedural service] to pay for these scenarios, and private payers are not taking your X modifiers, just use 59 for everyone,” he added.

Example: Chandler shared a story about a surgeon advising a room full of people at another conference to just add modifier 25 [ significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service] to every surgery. This is definitely not advisable. “Most of the time surgeons should not be reporting a separate E/M code, but there are certain times when they can,” he said. Keep in mind that overuse of modifier 25 can put a practice at risk of audit and should be used carefully.

Medicare also states that the decision to perform a minor procedure is included in the surgical package, especially for established patients. “The AMA specifically said that the discussion of alternative treatment options is considered pre-work, which is included in the minor procedure,” Chandler said. The question you can ask the practitioner is, “Did you perform multiple treatments for the same diagnosis? If so, one is a procedure and one is not. If you did, great, bill for it. If it was just discussed, you can’t,” he added.

Multiple Procedure Overlap

“Medicare states in the NCCI Manual that when you are performing two procedures in the same encounter, there is an area of overlap that happens. These are services that are provided in every procedure, but both are their own surgical package,” Chandler explained. He was referring to the pre-operative, post-operative care, the room, the instruments, etc. “To fix this, you would add modifier 51,” he said. He used a partial enterectomy along with a repair of a strangulated hernia as an example here. “You may have to explain to your practitioners that this is the reason their services are being reduced — Medicare only wants to pay for those overlapped items one time,” he said.

Separate Procedures

Separate procedure codes are those that specifically say (separate procedure) after the CPT^® code. This does not mean that they are all separately billable. A lot of practitioners aren’t aware of that, said Chandler. These codes are usually reported if they are the only procedure performed in the operative session. Some examples include:

• Component of a more complex service
• Procedures that are alone or unrelated to one another like: o Laparotomy (open and laparoscopic) o Lysis of Adhesions (open and laparoscopic)
• Endoscopic Procedures
• Chandler stated that endoscopic procedures are not separately reportable when:
• Used to verify placement or injury

Performed as an integral part of a larger procedure (An exception here is when it’s diagnostic to determine necessity of a larger procedure).

“For example, if a colonoscopy is performed to be sure an anastomosis is secure and not leaking, you cannot bill for the colonoscopy separately,” said Chandler. “One exception, however, is if the colonoscopy is done first to determine the extent of the situation and to inform the surgeon on what they need to do next,” he continued. Be sure to document the situation clearly and appropriately so the payer understands the situation.

Lindsey Bush, BA, MA, CPC, Development Editor II