Master Medicare’s Global Period & Collect Your Unrelated E/M Pay

Posted on 18 Dec, 2018 |comments_icon 0|By Elizabeth Debeasi
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Hint: Every service rendered in the global period isn’t necessarily reimbursed in the global package.

Without a clear understanding of Medicare global surgery packages, you could see an influx of claim denials as you unwittingly submit claims for services included in the global package and not separately billable. Even worse, though, you stand to lose substantial revenue if you dismiss reporting billable services during the global period, mistakenly thinking they’re included when they’re not.

Nail Down the Basics

Medicare employs three global surgical packages, each of which, for billing and reimbursement purposes, encompasses all necessary services routinely furnished before, during, and after a procedure by a surgeon or members of the surgeon’s group and specialty.

Based on the severity of the procedure, Medicare assigns it to one of the three surgical packages, essentially designating its global period, or number of post-operative days included in the package. The global package designation for a code is listed in the Medicare Physician Fee Schedule (MPFS).

CMS defines the three global periods as:

1. 0-Day Post-operative Period: Endoscopies and Some Minor Procedures, Codes with “000” in the MPFS

  • No pre-operative period
  • No post-operative days
  • Visit on day of procedure is generally not payable as a separate service.

2. 10-Day Post-operative Period: Other Minor Procedures, Codes with “010” in the MPFS

  • No pre-operative period
  • Visit on day of the procedure is generally not payable as a separate service.
  • Total global period is 11 days. Count the day of the surgery and the 10 days immediately following the day of the surgery.

3. 90-day Post-operative Period: Major Procedures, Codes with “090” in the MPFS

  • One day pre-operative included
  • Day of the procedure is generally not payable as a separate service.
  • Total global period is 92 days. Count 1 day before the day of the surgery, the day of surgery, and the 90 days immediately following the day of surgery.

Is the E/M Visit Unrelated to the Surgery?

But what happens if, during the global period, a patient returns to your practice for the evaluation of a different problem?

Remember: The global surgical package includes intraoperative services, as well as any preoperative visits that occur following the decision for surgery, any complications that are addressed postoperatively, any postop visits within the global surgical period, and any postsurgical pain management.

Services not covered in the global package include:

  • Initial consultation or evaluation when the patient’s condition is discussed
  • Diagnostic tests or procedures
  • Services by other physician groups
  • Postoperative complications that require a return trip to the operating room or ASC
  • Treatment for underlying conditions
  • Distinct procedures that are not reoperations or treatments for complications
  • Visits unrelated to the diagnosis for the surgical procedure.

Bottom line: If you’re fuzzy on the global surgical package and choose not to report the unrelated E/M visit, assuming it’s bundled into the surgery, your practice could be losing hundreds of dollars.

Collect Your Unrelated E/M Pay with Modifier 24

When your provider sees a patient for treatment of a condition that has nothing to do with the surgery, you can — and should — bill for the E/M services. Yes, even during the post-op period.

You’ll append modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to the E/M code.

Caution: Never append modifier 24 to a procedure code. It only applies to E/M codes.

Support Your E/M Claim with Documentation

Understand that auditors will examine your modifier 24 use to ensure the billed service is truly unrelated to surgery, so make sure the documentation details exactly what’s going on with the patient. If an auditor finds your provider only documented a postoperative visit and nothing more, you’ll likely receive a claim denial.

Other red flags include modifier 24 appended to a postop visit or documentation that states, “the patient presents for complications post-surgery.” Complications are covered in the surgical package.

Note: If the documented diagnosis for the E/M visit is the same as the surgical diagnosis, an auditor may question the claim. You aren’t required to have separate diagnoses, and if the patient suffers from a condition that has a nonspecific diagnosis code, using the same diagnosis might be appropriate. However, thanks to the specificity of ICD-10, where conditions can be specified, using the same diagnosis will invite scrutiny.

Use Modifier 78 for the Complication Exception

The one complication of surgery not covered in the global surgical package is when the patient must return to the operating room — but 24 isn’t the right modifier in this situation.

If the physician must return the patient to the OR to treat a postop complication, both Medicare and private payers should pay at a reduced rate when you attach modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to the surgical code.

Contributing Editor: Kristin Webb-Hollering

Learn More

Get fast, helpful, and accurate answers to your E/M coding and documentation questions — and find the help you need to secure your deserved pay — with your risk-free subscription to E/M Coding Alert Every issue of this monthly newsletter delivers coding and billing guidance, as well as high-impact tips to conquer the revenue-risking challenges that threaten your claims and compliance success.

With new modifiers, evolving payer policies, and the rise in modifier-focused audits, navigating the road to modifier success challenges even the top coders in the business. That’s why TCI created the Modifier Coding Handbook 2019. This comprehensive resource — brimming with essential information, proven strategies, and expert answers to questions from coders like you — untangles confusing modifier-related issues to save you time and streamline your coding processes for full and prompt reimbursement.

Author

Elizabeth Debeasi
Marketing Writer/ Editor

Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of Telehealth services.

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