Ob-Gyn Coding Alert

There is similar confusion among ob/gyn coders about the difference between a non-starred CPT procedure and one termed major by Medicare, say Melanie Witt, RN, CPC, MA, program manager for the Department of Coding and Nomenclature at ACOG and Susan Callaway-Stradley, CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., LLP, in Augusta, GA.

Medicares Global Package

Again the CPT and Medicare rules differ on their definitions of a global package. Medicares global package concept for major surgery is outlined in Sections 4821 and 15501.1 of the Medicare Carriers Manual and says:

All postoperative visits by the surgeon are included in the fee for the surgery for the designated 90-day follow-up period.

All services not related to the surgery are separately billable.

All medically necessary return trips to the operating room during the 90-day postoperative period are billable.Related surgeries do not change the follow-up period. Unrelated surgeries start a new follow-up period.

You may charge for the initial visit or consultation to determine the need for surgery. When this visit occurs the day of or the day before surgery, modifier -57 should be applied.

Preoperative visits, the day of or the day before the surgery, are included in the fee for the surgery and should not be billed separately.

The surgery itself and all usual and necessary intra-operative services required for the completion of the surgery are payable in the surgery global fee.

All services related to complications of the surgery that do not require a return to the operating room are included in the surgery global fee. This includes simple procedures performed at bedside or in a treatment room of your office.

CPT Global Concept for Major Surgery

The CPT definition of a global periodcalled a surgical packagediffers from Medicares in some significant ways.

For example, the CPT says the surgical package includes only the following elements:

the surgical procedure;

local or topical anesthetic or metacarpal or digital anesthetic blocks; and

normal, uncomplicated follow-up (postoperative) care.

Unlike Medicare, the CPT definition of a global period does not include preoperative services. According to the AMAs CPT Assistant, August, 1998: Preoperative services may differ based on several variables. Examples of some of these variables include ...the location of the surgery, and the insurance contract of each individual patient. Because it is not possible to address all of these concerns in a code descriptor, preoperative services are not included in the surgical guidelines in CPT.

The publication also says that necessary postoperative visits after the designated [by the payer] follow-up period may be coded separately and billed.

Note: The CPT surgical package definition applies to all codes in the Surgery section that are NOT starred procedures. This means that all the components are included in a single charge for the surgical procedure.

Commercial Payers Global Concept for Major Surgery

The majority of third-party payers have a blended surgical package. Like CPT, they recognize treatment of complications of the surgery, including additional E/M services. However, many of the carriers utilize the follow-up periods and other definitions of global services as designated by Medicare. Check with your top five payers to be sure.

However, there are services common to Medicare, CPT, and payer guidelines. For example, with each surgical procedure, payers expect the surgeon will provide dressing changes, care of the operative incision, and removal of superficial hardware such as staples, skin level sutures, and any lines, tubes, and drains.