Wiki Global Days

[snyderk]

I understand the global days like a major surgery is 90 days including the day before surgery. What I dont understand for sure is the pt is inhopsital and the surgeon decides on the 3rd to do surgery. Is the 2nd paid for since the decision for surgery was made on the 3rd. Can anyone direct me to this in writing?

 

[colorectal surgeon]

Well, billable and payable are of course two different things. Assuming the patient was seen on the 2nd and 3rd and the decision for surgery (with the 57 modifier) is put on the 3rd E & M it is billable and should be paid. Apparently many insurance companies and CMS will deny one of those visits as not medically necessary. Any other thoughts?

 

[btadlock1]

Well, billable and payable are of course two different things. Assuming the patient was seen on the 2nd and 3rd and the decision for surgery (with the 57 modifier) is put on the 3rd E & M it is billable and should be paid. Apparently many insurance companies and CMS will deny one of those visits as not medically necessary. Any other thoughts?

So long as documentation supports the 57 modifier, the E/M resulting in the decision for surgery is payable, per CPT and CMS guidelines. The global surgical package includes one visit, subsequent to the decision for surgery, for a pre-op evaluation. If there's a visit between the decision for surgery, and the day of the surgery that's not related to the surgery (eg, is NOT a pre-op evaluation, but happens to occur the day before the surgery), it should also be payable, but only once it's been appealed. It'll deny as part of the global package, because there's no way to identify it as separate if it's not the decision for surgery, and it's not on the day of the surgery. You just have to appeal it with records. If the patient's condition warrants evaluation (and that's reflected in the physician's documentation), then you should be able to show enough medical necessity to overcome a denial, in the event that you encounter one. Hope that helps!