Urology Coding Alert

Contacting individual payers before submitting surgical package claims (50010-55865, except 51725-51797 for urodynamics) will help you to sort out the appropriate CPT or Medicare definition to use for a global period, advises Mark Cendron, MD, associate professor of surgery for Urology and Pediatrics at Dartmouth Hitchcock Medical Center, Lebanon, N.H. It is particularly important that you resolve early on what your payers guidelines are on the lengths of post-operative services, because CPT and Medicare definitions for surgical packages differ markedly, Cendron adds.

In addition, third party payers may have their own guidelines regarding what constitutes an appropriate length of time for the global period, or follow-up for surgical services and procedures. Indeed, the differences in the global period can range from 21 days to as much as 90 days of follow up for the same procedure.

Within the Global Period

If the post-operative procedure does not fall within the global period, then the urologist is entitled to independently claim reimbursement under both CPT and Medicare guidelines. If the procedure occurs within the global period, then the office procedure is considered a normal complication of the initial surgery. For instance, a patient returns to see the urologist with a wound infectioncomplications from a cystotomy (51520)within the global period and is treated during the office visit. If the exam is part of the surgical global package and the procedure is considered a normal complication of surgery, then the service is not billable.

CPT, for example, 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 (post-operative) care.

However, preoperative services are not included in this CPT definition, although they are under Medicare. 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. From a strict CPT standpoint, the global package consists only of normal, uncomplicated follow-up care.

Major Surgeries Outlined

Medicares global package concept for major surgery includes all post-operative visits, supplies, and post-operative pain management for 0-10 days following surgery for minor procedures and endoscopies, and for 90 days following major surgeries, according to Section 4821 of the Medicare Carriers Manual (MCM). Medicares global package for major surgeries outlined in the manual states:

- All post-operative 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 post-operative
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.

- Pre-operative 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 period.

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.

Section 4821 of the MCM also states: Components of a Global Surgical Packageapply the national definition of a global surgical package to all procedures with the appropriate entry.

The Medicare-approved amount for these procedures includes payments for the following services related to surgery when furnished by the physician who performs the surgery. The services included in the global surgical package may be furnished in any setting, e.g., hospitals, [ambulatory] clinics, physicians office. Visits to a patient in the intensive care or critical care unit are also included if made by the surgeon. However, critical care services (99291-99292) are payable separately for minor procedures.

Complications Following SurgeryAll additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications which do not require additional trips to the operating room.

This Health Care Financing Administration (HCFA) definition considers as part of the global surgical package any services due to complications that do not require a return to the operating room. As you can see, HCFAs approach contradicts the CPTs, which limits the global package to normal, uncomplicated follow-up care.

Use Modifiers Correctly

In the example of wound infection, many practices would charge for a debridement with an in-patient post-operative cystotomy if it involved a wound infection. Either the modifier -58 (staged or related procedure service by the same physician during the post-operative period) would be used, or modifier -79 (unrelated procedure or service by the same physician during the post-operative period). In some cases, modifier -78 (return to the operating room for a related procedure during the post-operative period) would apply.

1. Modifier -58: In the case of modifier -58, CPT Assistant says, the physician may need to indicate that the performance of a procedure or service during the post-operative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the initial procedure; or c) for therapy following a diagnostic surgical procedure. This circumstance may be reported by adding the modifier -58 to the staged or related procedure, or the separate five-digit modifier 09958 may be used. This modifier may not be used if the treatment puts the patient back in the operating room.

Cendron says -58 is the most appropriate modifier to use if the debridement is performed in the office within the global period of the initial cystotomy. He also stresses the importance of verifying what the global period is for each of the carriers because it varies so widely among carriers.

2. Modifier -79: According to the CPT manual, the physician using the modifier may need to indicate that the performance of a procedure or service during the post-operative period was unrelated to the original procedure. (This circumstance may be reported by using the modifier -79 or by using the separate five-digit modifier 09979.)

An example would be a situation in which a patient with kidney stones originally had an endoscopy and the insertion of a stent (50575), then returns to see the urologist with a urinary retention problem caused by a blocked catheter, Cendron says. The blocked catheter is not related to original surgery, he explains.

Because modifier -58 is used only with a staged or related procedure, and because Medicare pays only if there is a return to the operating room, modifier -79 is the best option, agrees Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant from North Augusta, S.C., who would consider the wound debridement an unrelated procedure.

Generally, modifier -78 cannot be used if there is no return to the operating room for a related procedure during the post-operative period. However, the interpretation of this modifier is carrier-specific; indeed, a return to the operating room is not always a criteria. Check with your local carrier on two questions:

- Will it pay for a related procedure performed in the office during the global period of the cystotomy?

- Does it require the -78 modifier to be added to procedures done in the office?

Dont Confuse Modifier -79 with -78

Sometimes it is easy to confuse modifiers -78 and
-79. Both unbundle the subsequent procedure from the global period of the first surgery so it can be paid; however, using the wrong one can result in a longer global period for the primary procedure. When you append -78, a new post-operative does not begin with that related procedure, therefore, another 90 days is not added to the global period. For example, if a patient requires a return to surgery for a related problem 75 days after the initial surgery under the 90-day global period, 15 days would be left on the global period. E/M coding would apply after those days have passed.

But just how much does the reimbursement change with each modifier? This depends primarily on the documentation and the carriers determination. For modifier -78 for example, Medicare will reimburse no more than half of the intra-operative service, which is 69 percent of the total allowable. For most carriers, reimbursement within the global period figures as 10 percent of the total allowable for pre-operative services, 69 percent for intra-operative services, and 21 percent for post-operative services. To estimate the maximum reimbursement for procedures appended with -78, take 69 percent of the allowable and reduce it by half. (Dont, however, actually put these figures on your forms to Medicare.)

The difference in reimbursement between modifiers
-58 and -78 is considerable, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, Lakewood, N.J. The major effect between -78 and -58 is that with -78, you only get paid the intra-operative allowance for that procedure (the pre- and post-operative portions were paid in the first procedure) and the global clock does not reset. It remains based on the date of the first surgery. With -58, the physician is paid the full fee, but the global period starts with the day of the new surgery. So, if the first is minor (10 day global) and the second is major (90 day), modifier -58 would probably be justified as it is going to be more invasive and justify the resetting of the global period.

Note: Practices that knowingly or unknowingly bill for bundled services included within the global period may find themselves at the very least closely monitored, and at the worst, subject to an investigation for fraud because the reimbursement filing would be considered a deliberate attempt to double bill the payer. Check with your top payers to be sure you understand their definitions and expectations for a global period.