Otolaryngology Coding Alert

Although a surgical procedure typically only lasts one day, your ear, nose, and throat specialist’s services may span months after the actual surgery — and in most cases, insurers won’t reimburse separately for those follow-up visits during the global period. Because the pre- and post-surgical care is included in the global surgical package, it’s important to understand what the global period involves and how long it lasts.

Global periods may be irrelevant for some procedures, but they can last up to 90 days for others, said NGS Medicare’s Nathan Kennedy during the Part B payer’s May 12 webinar, “Medicare Global Surgery Policy.”

Read on for the lessons that Kennedy shared so you can understand exactly when global periods apply, and what the rules are.

1. Know What the Global Surgical Package Includes

“Global surgery is one of the things that we sometimes forget about, but it’s been around for 30 years now,” Kennedy said. “The global surgery concept includes all of the necessary services by the physician or the nonphysician practitioner before, during, and after the surgical procedure.”

The word “global” refers to the fact that the entire package encompasses everything related to the surgical service and the recovery period, so providers get one amount rather than billing for the pre- and post-surgical components a la carte.

The global package not only includes services provided by the surgeon during the global period, but also other providers in the same group and specialty during that period, Kennedy added.

2. You Can Find Global Periods in the Fee Schedule

If you’re curious about the global period for a particular otolaryngologic procedure, you can check the Medicare Physician Fee Schedule, Kennedy said. Under “global days,” you’ll see the number of days included in the global period, with the following as a guide:

• 000: This period indicates that related preoperative and postoperative care on the day of the procedure are included in the fee for the procedure itself. Any related evaluation and management (E/M) work done on the same day as a procedure with this global indicator is generally included. For instance, under Medicare guidelines, 31255 (Nasal/ sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)) has a global period of 0 days. Therefore, any related E/M procedures performed on the same day of service are typically not separately reportable.
• 010: This period indicates that Medicare includes 10 days of postoperative care in the payment of a procedure. Any E/M services you perform on the day of the procedure and during the 10-day global period “are generally not separately reimbursed,” Medicare guidelines indicate. As an example, code 69433 (Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia) carries 10 global days.
• 090: Procedures with 90-day global periods have one day of preoperative care prior to the day of surgery and 90 days of postoperative care following the surgery included in the fee for the initial procedure. For instance, code 42830 (Adenoidectomy, primary; younger than age 12) has a 90-day global period.
• XXX: Codes assigned “XXX” are not subject to the global period concept. This designation is typically seen with E/M, audiometric testing, allergy testing, allergy immunotherapy, lab tests, and radiology tests, but may be seen with other services.

Medicare lists the global periods in its fee schedule, but you should ask private payers for their global periods and policies in writing, because they may differ from Medicare’s. For example, there are commercial payers that might set a 14-day global for many procedures that have a 10-day global in the Medicare fee schedule. The global days can also be found in your encoder, for example in the fee schedule in Codify.

3. Some Services Are Excluded From the Global Package

“As far as services excluded from global surgery, first, and probably most important, is the initial evaluation and determination for a major surgical procedure,” Kennedy said. Codes with a 90-day global period are considered major surgeries. If the decision for surgery E/M service is performed on the same day, or the day before an unscheduled surgery, you should append modifier 57 (Decision for surgery) to receive separate payment for the E/M work, he said.

Procedures with global periods of 0 or 10 days are generally considered “minor procedures.” Because of this designation, Medicare and private payers don’t pay separately for the exams performed on the same day. In order to get paid for a separately identifiable and medically necessary office visit performed on the same day as a minor procedure, you have to ensure that the documentation supports a significant, separately identifiable visit, in which case you can append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Not included in the surgical package are visits provided by physicians in different group practices or in a different specialty in the same group. “But we still advise you that even if it’s a different physician of a different specialty, if they’re in the same group, that you should still use the global surgery modifiers to indicate those are different,” Kennedy advised. “Some of the editing that CMS [Centers for Medicare & Medicaid Services] has in place is based on tax identification number and we’ve seen several instances where even though they are different specialties they still get pulled into the global surgery policy and editing.”

Also not included in the surgical package are visits addressing other diagnoses, he said. “It’s possible that physician could do surgery for one condition and then still continue to see the patient after surgery for other conditions,” he said.

Finally, diagnostic tests are not considered part of the global package. Tests performed during the global period are usually separately payable.

4. Global Modifiers Can Help

In some cases, you may need to use modifiers to tell your payers that you performed services during the global period that were unrelated to the surgery. For instance, if the patient returns to the practice during the global period for evaluation of a different problem, you can append modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to the E/M code. “Modifier 24 tells the payer, ‘Yes, the service was rendered during this patient’s global period, but it’s not related. It has nothing to do with that surgery,’” Kennedy said.

You should also know how to use modifiers 54 (Surgical care only) and 55 (Postoperative management only), Kennedy said. “This is for a split care situation.” For instance, suppose a young patient travels to an out-of-state hospital for an adenoidectomy, but a physician in his hometown is performing all of the surgical aftercare following discharge.

In this case, the surgeon will bill the surgical code with modifier 54 appended to it, and the hometown doctor will submit the claim using the same date as the original surgery and the original surgical code with modifier 55 appended. In the “remarks” field of the claim form, the physicians should each indicate the date they relinquished (in the case of the surgeon) or assumed (in the case of the hometown doctor) care. Keep in mind that the surgeon may also report modifier 55 if they keep the patient for a portion of the global period.

Use of the 54 and 55 modifiers takes coordination by the surgeon and postoperative care physician. There also must be a formal transfer of care between the two physicians, as well as communication between the surgeon and the postoperative care physician as to how the surgery was coded, since the physician submitting modifier 55 only will be submitting a claim with the surgical codes and dates. Because it is difficult to perform this coordination and the formal transfer of care, this division of care and payment does not happen as often as it has the potential to take place.