Wiki CMS/CPT Global Period

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dballard2004

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Im in a pickle here and need some guidance, please.

Is it correct that per CMS, a surgical complication is still included part of the global period unless the patient returns to the operating room? How does this apply to minor procedures done in a physician's office? Let's say a Medicare patient came in for a laceration repiar and five days later the wound gets infected. Would this fall under the global for CMS, or could we code this with an E/M and append -24 since it is a new condtion because the ICD-9 code changed?

What about a wound dehiscense in this case? If we had to resuture the wound, does this qualify as "return to operating room" since we had to repeat the procedure?

Thanks.
 
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Complications are not part of the Global Surgical Package

Per 2008 AMA CPT Manual, pg. 47, "Follow-up care for therapeutic surgical procedures includes only that care which is usually a part of the surgical service. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported." (Sorry I'm using the 2008 CPT, but I'm not in the office today and only have access to this one at home.)

When I review E&M's that have been initially denied as included in the global surgical package, the scenarios that you have described are ones that I would allow. Modifier 24 should be appended to the E&M's, but I still allow and state in my rationale that the clinical info supports complications from the procedure (wound dihis., infection, etc.) and that modifier 24 is "implied".

As I work for a private payer, I'm not sure about the CMS guidelines, except to say that if they are different from the above that this conflicts with standard CPT coding guidelines. In response to the mod 58 question, again, as a private payer, I would allow this as well.

*******************

PB
 
I want a second opinion on this senario. A patient has an Aqueous Shunt surgery (66180) and is seen in clinic for post op visit. On po visit 3 the doctors finds the tube to be misplaced and advises the patient to follow up in clinc the next day. On that day they doctor decides to perform out patient surgery on the patient the following day. I coded this senario as followed

92004-24 dx 996.59
92004-24-57 dx 996.59

The surgery was coded using a -78. I was asked why did i attach a -24 to the visit and why did i attach both the the second. My reply was that the first visit was a complication to surgery, new problem with add work up. The second visit was to recheck and perform the add work up and on that day the decision for surgery was made. It is my understanding that both modifier's are needed to clarify the reason for the visit. She questioned why would that be an unrealted E/M visit during post op but the procedure would require a -78. Related surgery ?? Would anyone agree this was coded correct and i should be able to bill for both visits ?? I understand the patient was in post op but i should be able to bill any complications to surgery along with a -24.
 
You are correct Dawson, CMS does not always follow CPT, complications are included in the global package. It doesn't matter where the procedure is done, if it has a global period the same rules apply to inpatient and outpatient.

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

Starting at the bottom of page 88 they give the definition of a global package.

WPSMedicare said the rationale for including complications is that some patients will have complications and some won't so they pay everyone somewhere in the middle. So if your patient has no complications you get paid more than you probably should and those cases should be enough to cover the times when you are providng more care than usual.

I don't personally agree with this logic but I think all Medicare reimbursement is too low anyway.

Laura, CPC, CEMC
 
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cpccoder2008,

The first thing I see is you are using a new patient code on an established patient, 92004.

Secondly, who is your payer? If it is medicare see my above post with the link to their policy on complications.

Laura, CPC, CEMC
 
katmryn78 said:
cpccoder2008,

The first thing I see is you are using a new patient code on an established patient, 92004.

Secondly, who is your payer? If it is medicare see my above post with the link to their policy on complications.

Laura, CPC, CEMC
Click to expand...


Sorry, it was an established patient i just wrote an e/m code off the top my head, it probably wasn't that high of a level either.. it was an insurance patient and they were taken back to the OR.
 
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To be totally honest with you this is the first time i have read about the comlications being included in global. A few of my co-worker's were under the impression that as long as you have two different diagnosis you can bill it with a -24 but i don't agree with that 100%. I would have to say i don't agree with Medicare on this one. There are alot of time's when a patient is inpatient after surgery and a complication arises and there are time's when these complication's will result in death. What if the patient catches a stap infection or some sort of post op infection and their immune system is just too weak to fight off the disease and the final results are death. The surgeron will follow that patient till the day of discharge because he performed the surgery. You will probably have another physician billing as well if the patient has some sort of infectious disease along with a staph or what ever. I just can't see why medicare would say all those visit's are in global. What if the patient is inpatient for 2-3 months ?? None of those charges are billable ??
 
Insurance and complications

I posted this sometime ago and never got a responce. According to CMS you can't bill complications of surgery because it is considered part of the surgical package, how do we know if insurance carriers follow CMS guidelines ?? We are in a seperate office than insurance so we don't have access to their website or the people who work with our insurance. I guess they would have to contact each carrier to see what guidelines they follow, also we bill medicaid, i would assume they follow CMS guidelines right ??
 
Insurance and complications

I guess this would be more of an insurance billing question but what if we billed out inpatient visit's with a complication diagnosis, would they pay or deny it ?? If they follow CMS guidelines i would assume they would deny it for global but would hate to chance it and they pay and we have to refund monies.
 
Discharge service included in the global package

I recently started working with an orthopedic physician and my background is with internal medicine. I encounter s few denias for discharge services as part of the global package. If the doctor admitted the patient, performed the surgery, follow up the patient in hosp and discharge the patient, are all the services included in the surgical global period or can i appeal the admission and discharge, what about the post op follow op in the hospital?please help!!!!!
Thank you
 
erosario said:
I recently started working with an orthopedic physician and my background is with internal medicine. I encounter s few denias for discharge services as part of the global package. If the doctor admitted the patient, performed the surgery, follow up the patient in hosp and discharge the patient, are all the services included in the surgical global period or can i appeal the admission and discharge, what about the post op follow op in the hospital?please help!!!!!
Thank you
Click to expand...

Yes, all services are included in global package except the admit. Global for ortho is probably 90 so anything 90 days after surgery is considered global.
 
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