General Surgery Coding Alert

Under Medicare guidelines as established by the Physician Fee Schedule, there are four primary global period classifications: 90-day, 10-day, zero-day and ZZZ (private payers may either follow Medicare guidelines or set their own). "Major" surgeries are those to which Medicare has assigned a 90-day global period. The global period begins one day prior to surgery and includes all services as outlined in CPT(see page 43). Most procedures familiar to general surgery coders qualify as major surgeries.

CMS assigns "minor" surgeries, including endoscopic procedures, a 10- or zero-day global period. The 10-day period begins the day of the surgery, while the zero-day period applies to the date of the procedure only, says Alice Church, CCS-P, coding and reimbursement analyst for Wolcott, Wood & Taylor Inc.,and chief billing officerfor the University of Illinois Hospital physicians in Chicago.

The ZZZ global period applies to add-on codes only (these are easily identified in CPTby the addition of a "+" before the code, for instance, +43635, Vagotomy when performed with partial distal gastrectomy [list separately in addition to code(s) for primary procedure]). Because add-on procedures are by definition related to another procedure, they are always included in the global period of the "parent" code, that is, the primary, related surgical procedure. For example, if the surgeon performs partial gastrectomy with vagotomy, the appropriate coding is 43631 (Gastrectomy, partial, distal; with gastroduodenostomy) and 43635. The global period for 43631 is 90 days. Because 43635 is an add-on code with a ZZZ global period, all components of the global surgical package related to 43635 are included in the 90-day global period of its parent code, 43631.

The Fee Schedule provides three other global period classifications in addition to the four explained above: MMM (maternity codes, for which unique global rules apply), XXX (global surgical rules do not apply), and YYY(carrier determines global period). Surgical coders shouldnt worry about maternity codes, and you may ignore all global surgical rules for procedures with an XXX global period. If Medicare assigns a YYYglobal period, be sure to check with your local carrier regarding its policy on that particular code.

Note: Although Medicare sets the standard for use of surgical packages and billing during the global period, third-party payers can and do differ. In the absence of specific guidelines to the contrary, you should bill third-party payers according to CPTrules or, better yet, check with the insurer to avoid costly denials.