CPR’s “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.

Question: We are an orthopedic practice with a pain management/anesthesiologist as part of our group. Our orthopedist performs the surgical procedure, and the practice then schedules follow-up pain management with the anesthesiologist. We have received denials from payors citing that the anesthesiologist/pain management visit is included as part of the global surgical procedure. Can you explain the components of the global period and provide clarity on what is included in it?

Answer: The global period, or global surgical package, is a reimbursement convention that bundles all care typically related to surgical service into a single payment.

CPT® defines the surgical package as including the operative procedure itself, as well as:

• Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia
• Subsequent to the decision for surgery, one related evaluation and management encounter on the date immediately prior to or on the date of the procedure (including history and physical)
• Immediate postoperative care, including dictating operative notes and talking with the family and other physicians
• Writing orders
• Evaluating the patient in the post-anesthesia recovery area
• Typical postoperative follow up care

The Centers for Medicare & Medicaid Services (CMS), which devises Medicare rules, defines the global period to include:

• Preoperative visits after the decision is made to operate. For major procedures, this includes preoperative visits the day before the day of surgery. For minor procedures, this includes preoperative visits the day of surgery
• Intraoperative 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 postoperative period of the surgery because of complications, which do not require additional trips to the operating room
• Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery
• Post-surgical pain management by the surgeon
• Supplies, except for those identified as exclusions
• Miscellaneous services, such as dressing changes; local incision care; removal of operative pack; removal of cutaneous sutures, 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

The following services are never bundled, per CMS, and may be billed separately during the global period:

• Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier “-57” (Decision for surgery). This visit may be billed separately only for major surgical procedures.
• Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record or ambulatory surgical center record.
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery
• Treatment for the underlying condition or an added course of treatment, which is not part of normal recovery from surgery
• Diagnostic tests and procedures, including diagnostic radiological procedures
• Clearly distinct surgical procedures that occur during the postoperative period, which are not re-operations or treatment for complications
• Treatment for postoperative complications requiring a return trip to the operating room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).
• If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.
• Immunosuppressive therapy for organ transplants
• Critical care services (CPT® codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician

Count the days

When a global package begins and ends depends on the type of procedure or service being reported.

• A “minor” procedure is assigned a 0- or 10-day global period. A 0-day global means there is no preoperative period and no postoperative days. That is, the global package applies for one day only (the day of the procedure or service).
• A 10-day global has no preoperative period and a 10-day postoperative period. This means the global package applies for 11 days (the day of the procedure or service and for 10 days following).
• “Major” procedures have a 90-day global period. They are more resource-intensive than minor procedures and require a longer patient recovery. The global package for a major procedure begins one day before the procedure and includes the day of service and 90 days thereafter (total 92 days).

Global periods for all CPT® codes may be found using AAPC coder or other encoder software, or in the CMS Physician Fee Schedule Relative Value File. In addition to “000,” “010,” and “090” day global periods, you may also see indicators “XXX” (global period does not apply), “ZZZ” (add-on code), “YYY” (global period determined by payer) and “MMM” (maternity).

Separate services

Note that when reporting separately any service or procedure during the global period, as allowable per the CMS rules described, above, you may have to apply specific modifiers. Examples include modifier 57 Decision for surgery, modifier 58 Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period, or any of several others. To learn more about these modifiers and when to apply them, see “Your Quick Guide to the Global Surgical Package.”

Finally, note that CMS defines “post-surgical pain management by the surgeon” as part of the global package. But some providers may prefer that this care be provided by another provider. For example, in the question above, an anesthesiologist is brought into the practice to provide postoperative pain management. Because this care is part of the global package, however, the anesthesiologist cannot bill separately for these services. In other cases, a provider may contract postoperative care work to a different provider. For example, an orthopedic surgeon may pay an anesthesiologist “per patient” to manage post-operative pain.