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.

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 a new car, so too are basic "service and repairs" included during the global period of a surgical procedure.

Not all E/M services during the global period are bundled. For instance, even though for most Medicare payers the global period begins on the day prior to surgery, you can receive separate payment if the surgeon makes the decision to perform surgery during an E/M service on the day of or the day before the procedure.

In the case of a major surgical procedure (that is, a procedure with a 90-day global period), Medicare requires that you append modifier -57 (Decision for surgery) to the appropriate E/M code to alert the payer that the service was not part of the global surgical package, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a physician reimbursement consulting firm in Lakewood, N.J., and vice president of the Coding and Reimbursement Network.

For example, while working in the yard and chopping wood, an established patient experiences sharp pain in his lower abdomen. After several hours of persistent pain and nausea, he arrives for an emergency office visit. Upon examination, the surgeon finds that the patient has suffered a serious hernia and schedules an immediate surgery for repairs. Although the global surgical package for 49650 (Laparoscopy, surgical; repair initial inguinal hernia) includes one presurgical E/M service, in this case the office visit led to the decision to perform surgery. Therefore, you may report it separately with modifier -57 at the level supported by documentation.

Modifier -57 is also appropriate for emergency department visits that result in immediate surgery. In contrast, Cobuzzi says, had the surgeon scheduled the procedure at a previous date and met with the patient the day of or day before the surgery for final evaluations, discussions, etc., the E/M service would be included in the global package. In all cases, documentation must verify that the physician made the decision for surgery during the visit in question.

According to Medicare rules (Medicare Carriers Manual, section 15505.1), in the case of a minor procedure (that is, a procedure with a zero- or 10-day global period, as well as procedures with an XXX global period), modifier -57 is not necessary. Rather, you may separately report the initial E/M encounter that prompted the procedure by appending modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Again, however, if the physician scheduled the procedure previously and does not perform a documented, distinct and significant E/M service in addition to the procedure on the same date of service, you may not report a separate E/M code.

The physician may receive separate reimbursement for an E/M service during the global period of a procedure he or she performed if the E/M service is for a new, unrelated patient complaint. Here, you should attach modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the E/M code to denote the separately identifiable nature of the service, Church says. In the above example, for instance, several weeks after the hernia, the patient complains to the physician that he has had worsening pain and stiffness in his neck and left shoulder. Concerned that the patient may have an additional injury, the physician performs a full E/M service. Because the E/M service is unrelated to the original procedure (hernia repair), the surgeon may report it separately with modifier -24 appended.

The diagnosis accompanying the E/M service may be different from that linked to the surgical procedure, or it may be the same. For example, a vascular surgeon performs a thrombectomy for a patient with deep vein thrombosis. This patient is also on long-term anticoagulant therapy, and the vascular surgeon provides an E/M visit not related to the surgery to monitor the patients coagulant status. This is separately billable even though the same diagnosis (deep vein thrombosis) applies.

If the physician provides an E/M service during the global period of a procedure provided by a non-partner physician with a different personal identification number for a patient complaint unrelated to the previous procedure, no modifiers are necessary.

Critical care services (99291/99292) do not qualify as typical pre- or postoperative care and therefore are not included in the global surgical package. If the surgeon provides critical care to a patient during a global period, he or she may charge separately for these services. Documentation must verify that the patient requires constant physician attendance and that the physician has met all other requirements for reporting 99291/99292. And Medicare specifies that the reason for critical care must be unrelated to the anatomic injury or general surgical procedure for which the patient underwent surgery (in other words, the diagnosis[es] linked to the surgery code[s] must be different from that linked to the critical care codes). For instance, a car crash victim requires emergency surgery for brain trauma, but requires critical care due to another injury such as severe internal bleeding, etc.

Next month: More on typical postoperative care and complications during the global period.