I have attached three articles that I think might help.
According to Medicare's global surgery rules, payment for surgical procedures includes the surgery itself (the intraoperative"" portion of the service)" as well as all postoperative care that does not require a return trip to the operating room for a duration of zero 10 or 90 days depending on the procedure. In addition the global surgical package generally includes all preoperative visits with the patient after the decision for surgery has been made beginning with the day before surgery for major procedures and the day of surgery for minor procedures i.e. procedures with zero- or 10-day global periods.
For example a patient previously scheduled to undergo laparoscopic cholecystectomy (47562 ... cholecystectomy) visits the surgeon the day before surgery for a final exam and to discuss last-minute concerns. In this case the E/M visit is included in the global surgical package for 47562 and you may not report it separately.
On occasion however the decision for surgery which is typically made days or weeks before may be made the day prior to or even the day of the operation. For instance the surgeon is asked to evaluate a patient for acute right-upper quadrant pain and tenderness and upon full evaluation decides the gallbladder must be removed and schedules an immediate laparoscopic cholecystectomy.
In such cases Medicare will allow separate reimbursement for the preoperative E/M service if certain conditions are met. The Medicare Carriers Manual (MCM) section 15501.1 instructs carriers to "Pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service was for the decision to perform the procedure." The modifier must be appended to the E/M service code not the surgical procedure code. Modifier -57 need not be appended to E/M services that would normally fall outside the global surgical period e.g. an E/M visit five days before surgery.
Therefore in the above example of emergency lap chole the surgeon may report both the surgical procedure and the examination that led to the decision to perform the surgery as long as modifier -57 is appended to the appropriate E/M service code e.g. 99243 (Office consultation for a new or established patient ...). Failure to append modifier -57 to the E/M code will result in the E/M service being bundled into the global surgical package for 47562 leading to a loss in deserved reimbursement. In addition documentation should specifically note that the E/M service resulted in the decision for surgery.
According to Medicare's global surgery rules, payment for surgical procedures includes the surgery itself (the intraoperative"" portion of the service)" as well as all postoperative care that does not require a return trip to the operating room for a duration of zero 10 or 90 days depending on the procedure. In addition the global surgical package generally includes all preoperative visits with the patient after the decision for surgery has been made beginning with the day before surgery for major procedures and the day of surgery for minor procedures i.e. procedures with zero- or 10-day global periods.
For example a patient previously scheduled to undergo laparoscopic cholecystectomy (47562 ... cholecystectomy) visits the surgeon the day before surgery for a final exam and to discuss last-minute concerns. In this case the E/M visit is included in the global surgical package for 47562 and you may not report it separately.
On occasion however the decision for surgery which is typically made days or weeks before may be made the day prior to or even the day of the operation. For instance the surgeon is asked to evaluate a patient for acute right-upper quadrant pain and tenderness and upon full evaluation decides the gallbladder must be removed and schedules an immediate laparoscopic cholecystectomy.
In such cases Medicare will allow separate reimbursement for the preoperative E/M service if certain conditions are met. The Medicare Carriers Manual (MCM) section 15501.1 instructs carriers to "Pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service was for the decision to perform the procedure." The modifier must be appended to the E/M service code not the surgical procedure code. Modifier -57 need not be appended to E/M services that would normally fall outside the global surgical period e.g. an E/M visit five days before surgery.
Therefore in the above example of emergency lap chole the surgeon may report both the surgical procedure and the examination that led to the decision to perform the surgery as long as modifier -57 is appended to the appropriate E/M service code e.g. 99243 (Office consultation for a new or established patient ...). Failure to append modifier -57 to the E/M code will result in the E/M service being bundled into the global surgical package for 47562 leading to a loss in deserved reimbursement. In addition documentation should specifically note that the E/M service resulted in the decision for surgery.
Reader Questions: Surgery Consults
- Published on Sat, Jul 01, 2000
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Question: When I am consulted in the hospital about a patient and I recommend surgery the next day, does the consultation fall in the 90-day global period because it was done the day before the surgery?
California Subscriber
Answer: No. Services on the day of a major surgery or on the day before a major surgery that resulted in the initial decision to perform surgery are not included in the global surgery period and may be billed separately, says Tammy Chidester, CPC, billing supervisor with Upshur Medical Management Services, a multi-specialty coding and billing service in Buckannon, W.Va. Whatever appropriate evaluation and management (E/M) code that is used should be appended with modifier -57 (decision for surgery), which indicates that the decision to perform the procedure resulted from this E/M, which therefore should be paid separately.
The global period does include many services, such as:
Preoperative visits after the decision for surgery, beginning with the day before the day of major surgery and the day of surgery for minor surgery.
Intraoperative services that are normally a usual and necessary part of a surgical procedure, routine complications, or complications after surgery that do not require a return trip to the operating room.
Postoperative visits related to the surgery.
Postoperative pain management.
Miscellaneous services or supplies.
A history and physical exam would be considered a usual and necessary part of a surgical procedure and would not be coded separately.
If the patient is not going directly to surgery or having surgery the following day, you may bill whatever level of E/M service you provided.
Reader Question: Decision for Surgery Payable Separately
- Published on Sun, Jul 01, 2001
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Question: One of my physicians attended a seminar in which he was told if he sees a patient in the emergency department (ED), and then performs a procedure (for example, an appendectomy), the E/M is part of the procedures global package and shouldnt be billed. I disagree: He had to do an examination, a history and medical decision-making to decide to perform the procedure. I believe he should bill an E/M with modifier -57, as well as the procedure. Who is correct?
Pennsylvania Subscriber
Answer: You are, says Arlene Morrow, CPC, CMM, a general surgery coding and reimbursement specialist in Tampa, Fla. The global surgery guidelines in the Medicare Carriers Manual, section 4821B, clearly state, the initial consultation or evaluation of the problem by the surgeon to determine the need for surgery is not included in a procedures global surgical package.
Therefore, if the surgeon performed an appendectomy (44950) after evaluating the patient in the ED and determining that surgery was required, the appropriate-level E/M code should be billed with modifier -57 (decision for surgery) appended.
Note: If a decision is made to perform a procedure with a 0- or 10-day global period, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be used in place of modifier -57.