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.
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:
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:
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.
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.
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.
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
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