Neurosurgery Coding Alert

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 sidebar, page 28). 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 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), you must append modifier -57 (Decision for surgery) to the appropriate E/M code to alert that 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, an established patient falls from a ladder while cleaning the rain gutters of his home. After several hours of persistent headaches, dizziness and other symptoms, he arrives for an emergency office visit. Upon examination, the surgeon finds that the patient has suffered a concussion and schedules an immediate surgery to evacuate a hematoma. Although the global surgical package for 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) includes one presurgical E/M service, in this case the office visit led to the decision to perform surgery and 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. By 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). But, again, if the physician scheduled the procedure previously and does not perform a distinct and significant E/M service in addition to the procedure, you may not report a separate E/M code.

Also, 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, several weeks after the hematoma removal, the patient complains to the physician that he has had worsening lower-back discomfort since his fall. Concerned that the patient may have spinal damage, the physician performs a full E/M service and orders several diagnostic procedures. Because the E/M service is unrelated to the original procedure (hematoma removal), the surgeon may report the service separately with modifier -24 appended. Adiagnosis(es) different from that linked to the surgical procedure must accompany the E/M service (to emphasize the separate nature of the service), Church says.

Note that if the physician provides an E/M service during the global period of a procedure provided by a physician with a different personal identification number (PIN) 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. In addition, 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.

When reporting critical care during the one-day "preoperative" portion of a global period, append modifier -25 to the applicable code(s). When reporting critical care during the postoperative portion of a global period, append modifier -24 to the appropriate code(s). For complete instructions on billing critical care, see Neurosurgery Coding Alert, June 2002.

Next month: Staged procedures, a further discussion of "typical" postoperative care as defined by CPT and CMS, complications during the global period, and appropriate use of modifiers -54 and -55.