Written by Nicole Benson, CPC, CPMA
The global surgical period is full of complexity with CMS guidelines and payers’ interpretation. The relationship between services performed and use of modifiers in conjunction with correct coding per CCI can be quite tricky. In recent years, it has become an area of scrutiny and audit focus as defined by the Office of Inspector General (OIG). In a 2013 transmittal, the OIG issued the following directive, “We will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during such a period were in accordance with Medicare requirements. Prior OIG work found that improper use of modifiers during the global surgery period resulted in inappropriate payments.”
A global period is initiated when procedural services are performed and defined as either a minor (0 or 10 day period) or major (90 day period) procedure/surgery. Services are not always limited to a particular setting and may be performed in a multitude of locations such as the office, inpatient or outpatient hospital, emergency room, ASC, or ICU / Critical Care units. This is dictated by the CMS or private payor place of service guidelines. The period is assigned to each CPT procedural code based on the level of complexity and ‘like’ services performed within the same surgical session. There are some exceptions to the bundling edit rules such as unrelated visits for a condition not indicated by the procedure (-24); return trips to the operating room (-78, -79) and distinct surgical procedures requiring a modifier 59 to support. Services such as a recasting of a healing fracture, diagnostic tests or radiology and laboratory services are typically not included in the reporting of the global procedure code.
Minor procedures, as defined by CMS guidelines, carry a pre and a post-operative value on the same date of service. Policy for minor procedures indicate that the history, exam, and medical decision-making directly related to the decision and performance of the minor procedure are not a separately reportable using an E/M service. An evaluation and management modifier 25 may be used to support a significant separately identifiable E/M on the same day of a minor procedure, but documentation must support this service. For example, a patient presents to his/her family care provider for knee pain associated with arthritis, the provider performs a history of the current condition and examination, and decides to perform a joint injection of the knee (CPT 20610). This minor procedure code has a 0 day global, therefore the E/M service would be included in the performance of the procedure and not separately reportable. In contrast, if a patient presents to clinic for follow up of chronic hypertension, and during the course of this visit complains of knee pain, then the provider does decide to perform a joint infection and also addresses the hypertension. Then two separate services would be appropriate with the application of a modifier 25 to the E/M service reported.
Major procedures, as defined by the guidelines, do not include the initial decision for surgery. If this decision occurs within 24 hours of the procedure, then a modifier 57 could be reported on the appropriate E/M service for reimbursement. A ‘decision for surgery’ made beyond the 24 hour window does not require a modifier, however, once a decision for surgery is made, pre-operative encounters for this specified purpose are part of the global package and should not be reported. An example of this would be a decision to perform surgery two months before the scheduled surgery day, but the patient returns for completion of an H&P one week prior to surgery. This encounter would be considered a pre-operative visit and would not be reportable unless there is indication of a new complication or concern.
Both minor and major procedures involving the post –operative period include return visits to the provider for follow up care and any complications that may arise. If a patient returns to the same provider with an unrelated condition during the global window, then the appropriate E/M service would be reported with a modifier 24 attached indicating this unrelated service. However, if the condition is truly a related complication, the diagnosis will likely be different, but the services would not be reportable unless the complication required a return trip to the operating room. Again, H&P for this purpose would not be reported as modifier 24 and is not appropriate. Only the surgical services would be reported with the correct global modifier applied to the procedure code.
Global surgical modifiers 58, 78, and 79 will be covered in part II of our global surgery blog.
http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/WP01-Mcare_A+B.pdf