E/M Service: Global Surgery Denials

Denial Reason, Reason/Remark Code(s)

• CO-97 - Global Surgery Denials: Services submitted for the same patient by the same doctor on the same day as or within the post-op period of a major/minor procedure are bundled into the global surgery package and are not paid separately

Resources

• Before you submit a claim for post-surgical E/M services, verify the post-operative period by checking the surgery date and number of follow-up days associated with the surgical procedure
• Refer to CPT modifiers 24 and 25
• Access complete instructions for documenting and submitting CPT modifier 24 and 25 on the Palmetto GBA Modifier Lookup Web page, which you can find in the Self Service Tools of our home page 

Additional Modifiers May Apply
When a visit occurs on the same day as a surgery with '0' global days and within the global period of another surgery and the visit is unrelated to both surgeries, CPT modifiers 24 and 25 must be submitted.

To determine the global period of a surgery, refer to the Medicare Physician Fee Schedule database (MPFSDB). Access the database directly from the CMS website.

• CPT modifier 24:
  • This modifier may be used to indicate that an evaluation and management (E/M) service or eye exam, which falls within the global period of a major or minor surgery and which is performed by the surgeon, is unrelated to the surgery
  • This modifier may only be submitted with E/M and eye exam codes
  • Diagnosis is clearly unrelated to the surgery; supporting documentation is not required with the claim
  • Diagnosis may be related to the surgery or it is unclear whether the diagnosis is unrelated to the surgery: supporting documentation must be submitted with the claim. For electronic claims, submit supporting documentation in the documentation field. The documentation must substantiate that the service is unrelated to the surgery and may include the primary diagnosis code that reflects the reason for the E/M service.
  • Special note for ophthalmologists: If the exam and prior surgery were performed on different eyes, indicate this information clearly in the electronic documentation field. HCPCS modifiers RT and LT may not be submitted with eye exam codes.
• CPT modifier 25:
  • This modifier may be used to indicate that an E/M service or eye exam, which is performed on the same day as a minor surgery (000 or 010 global days) and which is performed by the surgeon, is significant and separately identifiable from the usual work associated with the surgery. Documentation in the patient's medical record must support the use of this modifier.
  • This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201 through 99205, 99281 through 99285, 99321 through 99323, and 99341 through 99345
  • No supporting documentation is required with the claim when this modifier is submitted
  • This modifier may be used to indicate that an E/M service was provided on the same day as another procedure that would normally bundle under Correct Coding Initiative (CCI). In this situation, CPT modifier 25 signifies that the E/M service was performed for a reason unrelated to the other procedure.
  • Before submitting this modifier, verify whether the services are bundled through CCI. CCI edits may be updated as often as quarterly. Access the CMS website for the National Correct Coding Initiative.
  • Code pairs identified with indicator '0' in the CCI list cannot be submitted separately for reimbursement under any circumstances. There are no exceptions to the CCI edits for indicator '0' codes.
  • Code pairs identified with indicator '1' may be submitted separately for reimbursement if the two services are performed in a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. Documentation must be maintained in the medical record to support the use of this modifier. No special documentation is required with the claim when CPT modifier 25 is submitted.
  • Code pairs identified with indicator '9' are not subject to CCI edits. No modifier is required in these situations.

References

• CMS Pub. 100-04, Chapter 12, Section 40.2.-40.5 
• CMS Pub. 100-04, Chapter 23, Section 30.2 

Was the E/M service performed by the same physician within the global period of a surgery?

• Is the E/M service unrelated to the surgery? If yes, see CPT modifier 24.
• Is the E/M service related to the surgery? If the E/M service is related to the surgery and is performed within the global period, the E/M service is not separately payable.

Was the E/M service performed by the same physician on the same day as a minor surgical procedure?
See CPT modifier 25 if the E/M service is significant and separately identifiable from the surgery (above and beyond the other service provided, or beyond the usual pre/post op care for the other procedure). If the E/M service is not over and above the usual preoperative and postoperative care associated with the surgery, the E/M service is not separately payable.

Did the E/M service result in a decision to perform major surgery (surgery with 90 follow-up days) that same day or the next day?

• If yes, submit CPT modifier 57 with the E/M service
• If no, the E/M service may not be submitted separately