General Surgery Coding Alert

So-called "global" periods which define a package of services or care associated with and bundled to a particular CPT code are among the most important but misunderstood coding concepts. Knowing when a global period begins and ends, what it includes, and when to append modifiers will make the difference between fair reimbursement and less-than-optimal payment, audits, or even civil or criminal penalties. The Surgical Package Includes Basic Services Except in rare circumstances, a surgeon does not arrive on the day of a scheduled surgical procedure, operate and leave, never to see the patient again. Rather, the physician will have met with the patient prior to surgery and will continue to follow up with him or her postoperatively, issue orders, discuss outcomes with the patients family, and so on.

Under the concept of a global surgical package, payment for such services typically associated with the surgical procedure is bundled to (that is, included as a part of and not separately reimbursable from) the surgical procedure, says Alice Church, CCS-P, coding and reimbursement analyst for Wolcott, Wood & Taylor Inc., and chief billing officer for the University of Illinois Hospital physicians in Chicago. CPT further explains, "The services provided by the physician to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services." Services bundled in the surgical package, and therefore not separately billable, include:

local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
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 and physical)
immediate postoperative care, including dictating operative notes, talking with the family and other physicians
writing orders
evaluating the patient in the postanesthesia recovery area
typical postoperative follow-up care. This would include services such as hospital rounds, dressing changes, removal of sutures, irrigation and removal of urinary catheters, etc., and under CMS rules includes management of postoperative pain (except in special circumstances that require the services of an anesthesiologist), as well as management of all postoperative complications that do not require a return to the operating room (non-Medicare payers do not consistently follow this rule). Of course, the physician cannot provide such bundled care indefinitely. Rather, payers (Medicare or third-party) establish finite global periods during which most related services are included as part of the surgical package but after which the physician once again can bill separately for E/M visits, etc. (see "Global Period Lengths Vary" on page 45). Just as you may receive free service and repairs for the first 12 months as part of the purchase price of [...]