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Coding Corner: Separate reporting of pre-, intra- and post-procedure work



October 30, 2018
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

“Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.

The global surgical package includes all “necessary services normally furnished” by a provider “before, during, and after a procedure,” as defined by the Centers for Medicare & Medicaid Service (CMS). When a provider is responsible for only a portion of the global package (e.g., an emergency department physician initiates fracture care, but the patient’s orthopedist provides follow-up care), compliant coding dictates that you append modifiers 54 Surgical care only and 55 Post-operative management only, as appropriate.

The “Global” Concept

CMS and other payors “bundle” services typically related to a surgical procedure into reimbursement for that procedure. This so-called “global surgical package” applies in any setting (e.g., inpatient hospital, outpatient hospital, ambulatory surgical center, physician office, etc.).

As explained in the MLN Global Surgery Booklet, Medicare includes the following services in the global surgery payment:

  • Pre-operative visits after the decision is made to operate. For major procedures, this includes pre-operative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.
  • Intra-operative services that are normally a usual and necessary part of a surgical procedure.
  • All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications that do not require additional trips to the operating room.
  • Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery.
  • Post-surgical pain management by the surgeon.
  • , except for those identified as exclusions.
  • Miscellaneous services, such as dressing changes; local incision care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts and splints; insertion, irrigation and removal of urinary catheters; routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

Services not part of the global package include visits unrelated to the diagnosis for which the surgical procedure is performed (unless due to complications of the surgery), diagnostic tests and procedure (including diagnostic radiological procedures), critical care services, and post-operative treatments that requires a return to the operating room, among others listed in MLN Global Surgery Booklet.

Although CMS, private payors, and the CPT® codebook all embrace the global package concept, they do not agree on what that package includes. For clarity, the rules covered in this article are for Medicare payers. Be sure to confirm the rules for your other payers.

Billing a Portion of the Global Package

When a health care provider performs a surgery, including all usual pre-and post-operative care, they may report that procedure using the appropriate CPT® code for the surgical procedure, only. Do not separately bill for visits or other services included in the global package.

If the provider who performs the surgical procedure, only (e.g., the “intraoperative” portion of the service), and does not furnish the follow-up care, the post-operative care is paid separately if the provider who performed the surgery and the provider who performs the post-op care agree on a transfer of care.

The provider who performed surgical care should append modifier 54 to the appropriate CPT® code(s) to describe the surgery performed. The modifier signals that the surgeon intends to relinquish “all or part of the post-operative care” to another provider, per CMS.

The physician who furnishes post-operative management services reports the same code(s) as the surgeon, but appends modifier 55. CMS advises, “Report the date of surgery as the date of service and indicate the date that care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.”

Per Medicare rules, “Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.”

The Takeaway: When appending modifiers 54 or 55, you must coordinate your coding with that of the physician who provides the other portion of care. Failure to cooperate in this way will likely result in one physician (usually the physician who provides postoperative care) missing out on reimbursement.

When Not to Use 54 and 55

CMS allows exceptions to the use of modifiers 54 and 55 for follow-up services during a post-operative period in the following circumstances:

  • Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate evaluation and management (E/M) code. No modifiers are necessary on the claim.
  • Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier.
  • If the services of a physician, other than the surgeon, are required during a post-operative period for an underlying condition or medical complication, the other physician reports the appropriate E/M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient. For more information, refer to the Medicare Claims Processing Manual, Chapter 12, Sections 40.2 and 40.4.

Medicare Won’t Accept Modifier 56

Modifier 56 Preoperative management only describes a provider’s pre-operative services, only. Medicare does not recognize modifier 56, and instead includes preoperative care in the payment for the intraoperative portion of the service. Guidelines may differ for other payors.

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