Orthopedic Coding Alert

The 90-day global surgical package has gotten quite a lot of press recently, and there still seems to be some confusion and misinformation out there. So let's look at what that "global package" is all about.

The global period rule reads, "To determine the global period for major surgeries, carriers count the day immediately before surgery, the day of surgery and the 90 days immediately following the surgery." This does, in fact, give you 92 days.

The actual 90-day countdown does not start until the day after the surgery took place, not the day of surgery. This can make tracking days tricky for the staff.

To simplify keeping track of global days, you can create a simple tool for your staff using a calendar.

The example to the right gives the January calendar for 2008. It shows the 90-day time limit under the date. If you do the math, you-ll see it is 91 days. The day immediately preceding makes this a 92-day window.

How it works: The number at the top is the January date. The numbers at the bottoms of the squares are the 91-day count out. For example, Jan. 1, 2008, would have a 91-day count out to March 31, 2008, or 1 in the top of the square translates to March 31 (3/31) in the bottom of the square. You can create these cheat sheets to see your time period at a glance.

All of this global period information is extremely important in pre- or postoperative care. You must be very careful to compare diagnosis information with each visit in this period. If the same diagnosis is the primary reason for the visit as was the primary for the surgery, payers consider this to be in the global period, and they would deny an E/M visit under the global rule.

Good news: Modifiers allow us to bill for these services during these periods, if the modifier chosen is correct for our documentation:

- Modifier 54 (Surgical care only) allows for billing of only the procedure and the care that goes along with it.

- Modifier 55 (Postoperative management only) allows us to follow the patient after the procedure but nothing else.

- Modifier 56 (Preoperative management only) allows us to bill for the patient's care before the provider initiates the surgery or procedure.

- Modifier 57 (Decision for surgery) allows for a visit the day immediately before the surgery, and payers will reimburse this E/M.

In today's mobile society, these modifiers are wonderful -- but there is a caveat. The total paid to all providers involved cannot and will not exceed the full reimbursement for that 90-day global package care.

For example: Mrs. Green, who lives in Pennsylvania, is visiting her daughter, who lives in Florida. While there, Mrs. Green falls and breaks her arm. She goes to the hospital, has an x-ray, and has a consultation with an orthopedist who performs an ORIF on her right wrist.

Mrs. Green's return plane tickets are two weeks from now, so some of her follow-up care will most certainly be done by her primary in Pennsylvania, or perhaps the primary may send her to another orthopedic specialist. Either way, her continuum of care will be interrupted, and the practitioners involved will have to communicate for all of them to be paid appropriately.

What does this mean to the biller? Your office must complete all coordination of all care prior to the procedure. All medical providers involved must be aware of what the care will be from each, and each must bill accordingly. That means using the proper modifiers and ensuring the codes are consistent.

Why? Because the first bill to hit the carrier's desk will be paid, the carrier will deny the other bills hitting later as duplicate(s) or already paid in full to another provider. This can flag an account for fraud. Then you will have to communicate so that whoever received the first payment returns it, everyone gets the codes right and everything gets resubmitted. Remember: The total payments made to the individual practitioners cannot exceed the total paid to one for a global service.

For this reason, the surgical coordinators in any office have so much more to do than just schedule the procedures. They really should be coordinating these efforts, and to do that they need to interview the patient extensively and ask about her plans for all that needs to be done regarding care and payment.

The most frustrating bills to collect are those for which you happen to be the last practitioner to get your bill to the carrier. Coordinating on the back end to get all the bills from all participants in the patient's care on track for all of you to be paid is a huge headache.

To be sure you code correctly during the global period, you have to understand what services your payer includes in the surgical package. And this can vary depending on whether the payer follows CPT or Medicare surgical package conventions.

CPT's view includes the following:

- the surgical procedure

- local infiltration or topical anesthetic

- one related E/M encounter (including history and physical) that occurs after the decision for surgery has been made

- immediate postoperative care (including dictating the operative notes and any conferring with the family and/or other physicians)

- writing orders

- evaluating the patient in post-anesthesia state

- typical postoperative care.

You should remember that "typical" in this sense refers to that care that is usually a part of the surgical service, such as looking at the healing progress, bandage changes when necessary, etc.

You should bill and separately report complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services.

This means from a CPT point of view the global surgical package extends from no more than one day before the day of the procedure to as long as is necessary for typical postoperative follow-up care. In other words, CPT makes this an open-ended issue.

Medicare's view of this global package is slightly different. The Web site http://www.cms.hhs.gov/manuals/14_car/3b4820.asp#_1_2 has a downloadable manual that explains every detail. What a biller needs to remember is that many other carriers use the Medicare model. Familiarizing yourself with the rules will help with all of the packages you have.

From Medicare's view, surgical packages include the following services when completed by the physician who performs the surgery:

- preoperative visits after the decision is made to operate, beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures

- intraoperative services that are a usual and necessary part of the surgical procedure

- all additional medical or surgical services required of the physician during the postoperative period because of complications not requiring additional trips to the operating room

- follow-up visits during the postoperative period

- postoperative pain management

- certain supplies, especially those needed for the procedure

- miscellaneous services, such as dressing changes, local incision care, removal of sutures, insertion, irrigation and removal of catheters, routine peripheral intravenous lines, nasogastric tubes, rectal tubes, and changes or removal of tracheostomy tubes. And of course, this is not intended to be an exhaustive list.

Services not included in the Medicare global fee definition include the following:

- the surgeon's initial consultation or evaluation of the problem to determine the need for the service

- services of another physician (except where the surgeon and other practitioners have agreed to split services to better serve the patient)

- visits unrelated to the global diagnosis, treatment of underlying condition, diagnostic tests and procedures (including radiological tests)

- clearly distinct services

- treatment for postoperative complications (in the operating room)

- certain services performed in the physician's office

- immunosuppressive therapy for organ transplants

- critical care services (99291-99292).

Note the distinctions between the two definitions.

First, Medicare includes treatment of complications, if they do not require a return trip to the operating room.

Second, unlike CPT, Medicare puts a number on the postoperative care days, which is 90 for major procedures, and zero to 10 for minor procedures. What this tells you is that you can bill separately any service after that 90-day period that is still related to the procedure and expect payment, which is good news.

As mentioned earlier, the decision for surgery has a modifier because it is a visit, which in the view of CPT and Medicare is never part of the global package. In addition, if this E/M visit takes place outside the day before surgery, you can bill it without the modifier. But if it takes place the day before the surgery, appending the modifier will ensure payment.

There are a few other issues to consider when discussing global packages.

Although the postoperative visits are not payable, you will want to keep track of them. There are many more places that claim information goes than just to get you paid. One way to easily keep track for your office and for the sake of patient records is to use 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure).

Another modifier worth keeping in mind is modifier 24 (Unrelated E/M service by the same physician during a postoperative period). Your choice of ICD-9 code will verify this.

Also, any surgical package concept that we have discussed never applies to all procedural services. For example, maternity care services have their very own global concept of payment. You can find more information concerning this idea at http://www.aafp.org/x19559.xml.

Lesson: The global surgical concept has been used for many years, and all practices, with few exceptions, have to follow these rules at one time or another. Educating ourselves about the rules allows us to understand and improve our bottom line using the rules for their intended purpose.

-- Alice Marie Reybitz, RN, BA, CPC, CPC-H, a healthcare coding and billing consultant based in Belleair, Fla., has been in the medical field for more than 20 years. She has worked as a receptionist, assistant, aide, biller, coder, office manager, director and nurse, and serves as medical billing and coding program coordinator for Keiser Career College in St. Petersburg, Fla.