In December 2006, one of the top reasons we denied claims was due to the Global Surgery Package. This article identifies services that are included in the global surgery payment, services that can be paid separately, and guidelines for submitting claims correctly.
How many post-op days are assigned to surgical codes?
Procedures are classified by the number of post-operative days assigned to them. Major surgical procedures are always assigned 90 post-operative days. Minor surgical procedures and endoscopies are assigned either 0 or 10 post-operative days.
How can I determine whether Medicare considers a procedure to be major or minor?
The best way to find information on a specific code is to utilize the database tool on the CMS Web site. The database, which is located at www.cms.hhs.gov/physicians/mpfsapp/step0.asp, is searchable by CPT and HCPCS codes and identifies the number of post-op days assigned to those codes. Once you've accessed the database:
- Select the year, whether you want information on a single or multiple codes, and 'Payment Policy Indicators', then click 'Next'
- After entering the code(s), select 'All Modifiers' and clicking 'Submit,' the database will display a table. Under the GLOBAL column, you will find either '090', '010', or '000' to indicate a '90-day', '10-day', or '0-day' post operative period, respectively.
- Please keep in mind that major procedures also include one pre-operative day (the total global period for major procedures is 92 days, including the day before, day of, and 90 days following the surgery)
- The total global period for minor procedures with 10 post-operative days is 11days, including the day of and 10 days following the procedure
Are there services that can be separately billed during the global period?
Yes. The following services may be submitted separately when performed by the surgeon. In some instances, an appropriate modifier/diagnosis is required.
- Initial consultation or evaluation codes (major surgeries only)
- Services of other physicians except where the surgeon and other physician(s) agree on the transfer of care
- Visits unrelated to the diagnosis for which the surgery was performed (unless the visits occur due to complications of surgery). Refer to CPT modifiers 24 or 25.
- Treatment outside of the normal recovery from surgery. Refer to CPT modifier 24.
- Diagnostic tests and procedures
- Clearly distinct surgical procedures performed by the original surgeon during the post-op period, which are not re-operations or treatments for complications. Refer to CPT modifiers 58 or 79.
- Treatment for post-operative complications that require a return trip to the operating room. Refer to CPT modifier 78.
- If a less extensive procedure fails and a more extensive procedure is required. Refer to CPT modifier 79.
- Immunosuppressive Therapy provided by the surgeon. Refer to CPT modifier 24.
- Critical care services (CPT codes 99291 and 99292) unrelated to surgery for critically injured or burned patients who require constant attention from physician. Refer to CPT modifiers 25 (for pre-op) or 24 (for post-op) and submit with ICD-9 codes in the range 800.90 ' 959.9 (except for ICD-9 codes 930.0 ' 939.9).
NOTE: The use of any modifier on a claim must be supported in the medical record.
What is the difference between CPT modifiers 24 and 25?
CPT modifier 24 is used to identify an Evaluation & Management (E/M) service as unrelated to either a major or minor surgical procedure performed in history, when the E/M falls within the post-op period of that procedure. When this modifier is used, an unrelated ICD-9 code and/or documentation must be submitted to indicate there is no direct relation between the E/M and the procedure previously performed. If the diagnosis for the E/M is related to the condition that resulted in surgery or represents the same body area, the E/M may be denied if documentation clearing stating why the E/M is unrelated to the procedure is not submitted with the claim.
Example
On December 13, Dr. Brown performed cataract surgery (CPT code 66984) on Mrs. Green's left eye. A few weeks later she developed a new problem with the same eye. Mrs. Green went back to Dr. Brown on January 17 for an evaluation of the new problem. Since this visit falls within the post-op period of the surgery, and it is unrelated to the surgery, the E/M should be submitted with CPT modifier 24. A clear statement explaining how the visit is unrelated to the surgery in history should be included with the claim.
CPT modifier 25 is used to report a significant and separately identifiable E/M service on the same day as a procedure.
Example
Mr. Redd is going to see Dr. Blue for a hypertension check. During the visit, Mr. Redd complains about a skin tag that is irritated. Dr. Blue examines the skin tag and finds it to be infected. He excises the infected skin tag (CPT code 11200) during the visit. Since the purpose of the visit is separately identifiable from the procedure, the E/M should be submitted with CPT modifier 25.
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