I refer to the
Medicare global surgery booklet frequently. If the surgeon is managing the inpatient stay, those standard visits (and discharge) are not payable in the global period.
Specifically:
What services are
included in the global surgery payment? Medicare includes the following services in the global surgery payment when provided in addition to the surgery:
• Pre-operative visits after the decision is made to operate. For major procedures, this includes pre-operative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.
• Intra-operative services that are normally a usual and necessary part of a surgical procedure
• All 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
• Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
• Post-surgical pain management by the surgeon
• Supplies, except for those identified as exclusions
• Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes
What services are
not included in the global surgery payment? The following services are not included in the global surgical payment. These services may be billed and paid for separately:
• Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier “-57” (Decision for Surgery). This visit may be billed separately only for major surgical procedures.
• Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record.
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery
• Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery
• Diagnostic tests and procedures, including diagnostic radiological procedures
• Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications
• Treatment for post-operative complications requiring a return trip to the Operating Room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).
• If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.
• Immunosuppressive therapy for organ transplants
• Critical care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.
I usually prefer the Medicare booklet over the claims processing manual, which is written from a more legal standpoint and not so much in plain language. That being said, the
Pub 100-4, Ch.12, §30.6.6 A referenced also clearly states it is only billable with -24 IF UNRELATED to surgery.
A. CPT Modifier “
-24” - Unrelated Evaluation and Management Service by Same Physician During Postoperative PeriodA/B MACs (B) pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT codes 99221-99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT modifier “-24,”
and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure. They do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery. All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment.
