Even though there’s been no change in the rules, we decided it was time to review the global rules and shed some light on two key questions about global: when to charge for an additional service and when not to charge for an additional service.
We have received a lot of questions about when to charge for a particular service during the global of another procedure. Even though there’s been no change in the rules, we decided it was time to review the global rules and shed some light on two key questions about global: when to charge for an additional service and when not to charge for an additional service. In this day and age, in which payments are tight and take-backs are frequent, both questions are of equal importance and will be addressed accordingly in this article.
CPT rules provide a foundation for all coding and billing rules. CPT rules do not directly address “global” or “bundling” rules; however, they do provide the basics by defining the surgical package (which covers both bundling and global rules) as quoted below. In this article, we will only address the global rules.
The American Medical Association CPT surgical package definition reads as follows:
“The services provided by the physician to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. In defining the specific services “included” in a given CPT surgical code, the following services are always included in addition to the operation per se:
In another note, CPT provides additional guidelines:
“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.”
As you can see, CPT does not include complications and does not apply specific days to the surgical package.
Payers need to implement more concrete policies for payment. And as payer rules always trump CPT rules, we remind you to pay attention to your contracts and payer-published rules.
As with other rules, Medicare, as the largest single payer, is the first place to look. Medicare has defined its surgical package as a “global” package.
Private payers normally follow Medicare rules to a certain degree, but most vary in one way or another. Time (and space) does not allow us to discuss all payers; we will only discuss Medicare rules.
Medicare clearly includes CPT concepts in many ways; for example, Medicare includes pre-operative and immediate post-operative care for all services with a global. Medicare goes further and defines all surgical procedures in three global periods: 90 days for major procedures and 10 days or 0 days for minor procedures and most endoscopies. However, Medicare does not follow CPT completely and in some cases has taken a position that contradicts CPT. For example, Medicare includes “complications” in its global surgical package.
Medicare’s definition of a global surgical package can be found in the Medicare Claims Processing Manual (Chapter 12, 40.1, Rev. 1, 10-01-03, B3-4821, B3-15900.2). As defined in the manual, the components of a global surgical package are as follows:
Medicare then establishes a list of services that should not be included in the global surgical package:
Typical of any Medicare rule, some parts are relatively straightforward and others require a bit more digging. One example from above that causes a great deal of confusion is the statement included in the first bullet, “The initial evaluation is always included in the allowance for a minor surgical procedure.”
Does this mean that if you evaluate a new patient for hematuria and decide to do a cystoscopy on the same day, you can’t charge for the initial visit? The short answer is no. Medicare’s intent in stating that the “initial evaluation is included” only refers to the initial evaluation for the usual pre-op evaluation for the procedure. We base our answer on years of instruction on the whole of Medicare rulings, which may provide seemingly contradictory instructions within the manual.
With respect to same-day E&M services, Medicare rules specifically state that you can charge for the visit by defining the use of the –25 modifier.
“Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service" (Medicare Claims Processing Manual, Chapter 12, 30.6.6, Rev. 954, Issued: 05-19-06, Effective: 06-01-06, Implementation: 08-20-06).
The example above concerning cystoscopy would qualify for the use of the –25 modifier as defined by Medicare, and the appropriate visit code would be charged with the –25.
In other words, a patient presenting for a cystoscopy or other minor procedure and no evaluation other than a routine history and physical to determine the patient’s readiness for the procedure on the day of service should not be charged an E&M service because the initial evaluation is included in the minor surgery package.
The bottom line is that if your documentation shows the medical necessity for providing a significant and separately identifiable service and supports the provision of the separately identifiable and significant service on the same date as minor surgical procedure, an E&M visit can be charged with the –25 modifier.
Medicare rules must be taken in total when considering the billing concepts related to global surgical services. When a situation arises that does not fit what you know, double-check all the rules that may apply to your situation and ask an appropriate source if you remain unclear. Remember that the question you ask will guide your answer, and when asking any payer about a rule interpretation, get a response in writing and from more than one person.UT
The dos and don’ts listed below are provided to answer questions that we have been asked.
• For the initial evaluation of the patient, over and above the evaluation for pre-op services
• Example 1: Patient is evaluated for a disease process and the decision is made to perform a procedure on the same day.
• Example 2: An established patient is evaluated for an exacerbation of a problem or new problem and the decision is made to perform a procedure on the same day.
• Use modifier –57 or modifier –25 for an E&M reported with 90-day global: use modifier –25 for an E&M reported with a 0- or 10-day procedure.
• For the discussion of the treatment of the disease process that is significant and separately identifiable in the patient record following a cystoscopy and after you have explained to the patient the findings of the cystoscopy (applied the –25 modifier to the appropriate E&M code)
• For the additional history, physical, and/or medical decision making for an disease unrelated to the procedure (E&M plus –25 modifier)
• For intra-operative services that are not normally a usual and necessary part of a surgical procedure (modifier –51 or –59 depending upon the current CCI)
• For all medically necessary non-global services. Examples: Laboratory test, x-rays, urinalysis, ultrasound for post-void residual, uroflow, etc. (no modifier required)
• For surgeries due to complications in the postoperative period if performed in an OR, dedicated endoscopy, or procedural room (–78 modifier)
• For unrelated E&M services (–24 modifier)
• For unrelated surgical procedures (–79 modifier).
• For routine pre-op care, starting the day before the surgery for a 90-day global procedure and the day of the procedure for a 0- or 10-day global procedure
• For routine postoperative care including treatment for complications unless provided in an OR or endoscopy suite, as stated above
• For any medically unnecessary tests or treatments.
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