Neurosurgery Coding Alert

The global period's length for a given procedure has important consequences, including how you should use modifiers (see -Check These 5 Items to Apply Modifier 57 Properly- on page 75) and when during the postoperative period you can report -related- procedures or services (such as follow-up E/M services or postoperative complication care).

So, what are the global period classifications, and how can you find them?

Under CMS guidelines as established by the Physician Fee Schedule, there are five primary global period classifications: 90-day, 10-day, zero-day, ZZZ and XXX. Private payers may follow Medicare guidelines or elect to assign their own global period categories.

-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. Most procedures familiar to neurosurgery coders that take place in the operating room 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. The zero-day period begins the day of the procedure and includes related preoperative and postoperative care for that date only.

The ZZZ global period applies to add-on codes only (you can easily identify these in CPT by the -+- before the code, for instance, +63048, Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; each additional segment, cervical, thoracic, or lumbar [list separately in addition to code 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 cervical laminectomy with decompression at two vertebral segments, the appropriate coding is 63045 (... cervical) and 63048. Because 63048 is an add-on code with a ZZZ global period, all components of the global surgical package related to 63048 are included in the 90-day global period of its parent code (63045).

Services and procedures with an XXX global indicator include only the service or procedure itself, along with any (minor) -inherent- E/M component. Because these procedures do include a minor E/M service, if the surgeon documents a significant, separately identifiable E/M service on the same day as a procedure with an XXX global period, you will still have to append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M service to gain full payment. If you do not append modifier 25, the payer will bundle the E/M service to the procedure.

The fee schedule includes two additional global period classifications: MMM (maternity codes, for which unique global rules apply) and YYY (the carrier determines the global period).

Neurosurgical coders shouldn't worry about maternity codes. If Medicare assigns a YYY global period, however, be sure to check with your local carrier regarding its policy on that particular code.

Because CMS, not the AMA, designates global periods, you will not find them in the CPT manual. Instead, you can find global periods in Medicare's Physician Fee Schedule Database, available at www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp?listpage=3.

To determine the global period for a particular procedure, simply check the fee schedule's -GLOB DAYS- column. If you see a -090- in the GLOB DAYS column, the selected code is a major surgical procedure. Likewise, a -010- indicates a 10-day global, a -000- designates a zero-day global, and so forth.

More to come: Look to future editions of Neurosurgery Coding Alert for additional information on the importance of global periods, including how to report postoperative complications and -staged- procedures, as well as what procedures and services payers include in the global surgical package.