Global rules: Know when to charge (and not to charge)

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:

• Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia

• Subsequent to the decision for surgery, one related evaluation and management (E&M) encounter on the date immediately prior to or on the date of procedure (including history and physical)

• Immediate postoperative care, including dictating operative notes and talking with the family and other physicians

• Writing orders

• Evaluating the patient in the post-anesthesia recovery area

• Typical postoperative follow-up care.”

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 rules similar, different from CPT

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:

• Visits to a patient in an intensive care or critical care unit

• Preoperative visits: Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures

• Intra-operative services: Intra-operative services that are normally a usual and necessary part of a surgical procedure

• Complications following surgery: All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room

• Postoperative visits: Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery

• Postsurgical pain management: By the surgeon

• Supplies, except for those identified as exclusions

• Miscellaneous services: Local incisional care; insertion, irrigation, and removal of urinary catheters.

Medicare then establishes a list of services that should not be included in the global surgical package:

• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure.

• Services of other physicians

• 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 that is not part of normal recovery from surgery

• Diagnostic tests and procedures, including diagnostic radiologic procedures

• Clearly distinct surgical procedures during the postoperative period that are not re-operations or treatment for complications

• Treatment for postoperative complications that requires 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.

• If a less extensive procedure fails and a more extensive procedure is required, the second procedure is payable separately.

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.

Billing for same-day E&M services

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

Global dos and don’ts

The dos and don’ts listed below are provided to answer questions that we have been asked.

Do charge:

• 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).

Do not charge:

• 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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