E/M Service: Global Surgery Denials co 97

Denial Reason, Reason/Remark Code(s)

•    CO-97 - Global Surgery Denials: Services submitted for the same patient by the same doctor on the same day as or within the post-op period of a major/minor procedure are bundled into the global surgery package and are not paid separately

Resources
•    Before you submit a claim for post-surgical E/M services, verify the post-operative period by checking the surgery date and number of follow-up days associated with the surgical procedure
•    Refer to CPT modifiers 24 and 25
•    Access complete instructions for documenting and submitting CPT modifier 24 and 25 on the Modifier Lookup.

Additional Modifiers May Apply
When a visit occurs on the same day as a surgery with '0' global days and within the global period of another surgery and the visit is unrelated to both surgeries, CPT modifiers 24 and 25 must be submitted.

•    CPT modifier 24:

o    This modifier may be used to indicate that an evaluation and management (E/M) service or eye exam, which falls within the global period of a major or minor surgery and which is performed by the surgeon, is unrelated to the surgery

o    This modifier may only be submitted with E/M and eye exam codes

o    Diagnosis is clearly unrelated to the surgery; supporting documentation is not required with the claim

o    Diagnosis may be related to the surgery or it is unclear whether the diagnosis is unrelated to the surgery: supporting documentation must be submitted with the claim. For electronic claims, submit supporting documentation in the documentation field. The documentation must substantiate that the service is unrelated to the surgery and may include the primary ICD-9 code that reflects the reason for the E/M service.

o    Special note for ophthalmologists: If the exam and prior surgery were performed on different eyes, indicate this information clearly in the electronic documentation field. HCPCS modifiers RT and LT may not be submitted with eye exam codes.

•    CPT modifier 25:

o    This modifier may be used to indicate that an E/M service or eye exam, which is performed on the same day as a minor surgery (000 or 010 global days) and which is performed by the surgeon, is significant and separately identifiable from the usual work associated with the surgery.
Documentation in the patient's medical record must support the use of this modifier.

o    This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201 through 99205, 99281 through 99285, 99321 through 99323, and 99341 through 99345

o    No supporting documentation is required with the claim when this modifier is submitted

o    This modifier may be used to indicate that an E/M service was provided on the same day as another procedure that would normally bundle under Correct Coding Initiative (CCI). In this situation, CPT modifier 25 signifies that the E/M service was performed for a reason unrelated to the other procedure.

o    Before submitting this modifier, verify whether the services are bundled through CCI. CCI edits may be updated as often as quarterly. Access the CMS website for the National Correct Coding Initiative.

o    Code pairs identified with indicator '0' in the CCI list cannot be submitted separately for reimbursement under any circumstances. There are no exceptions to the CCI edits for indicator '0' codes.

o    Code pairs identified with indicator '1' may be submitted separately for reimbursement if the two services are performed in a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. Documentation must be maintained in the medical record to support the use of this modifier. No special documentation is required with the claim when CPT modifier 25 is submitted.

o    Code pairs identified with indicator '9' are not subject to CCI edits. No modifier is required in these situations.

Was the E/M service performed by the same physician within the global period of a surgery?
•    Is the E/M service unrelated to the surgery? If yes, see CPT modifier 24.
•    Is the E/M service related to the surgery? If the E/M service is related to the surgery and is performed within the global period, the E/M service is not separately payable.

Was the E/M service performed by the same physician on the same day as a minor surgical procedure?
See CPT modifier 25 if the E/M service is significant and separately identifiable from the surgery (above and beyond the other service provided, or beyond the usual pre/post op care for the other procedure). If the E/M service is not over and above the usual preoperative and postoperative care associated with the surgery, the E/M service is not separately payable.

Did the E/M service result in a decision to perform major surgery (surgery with 90 follow-up days) that same day or the next day?
•    If yes, submit CPT modifier 57 with the E/M service
•    If no, the E/M service may not be submitted separately

 


 Adjudication of Claims for Global Surgeries


A.Fragmented Billing of Services Included in the Global Package

Since the Medicare fee schedule amount for surgical procedures includes all services that are part of the global surgery package, A/B MACs (B) do not pay more than that amount when a bill is fragmented. When total charges for fragmented services exceed the global fee, process the claim as a fee schedule reduction (except where stated policies, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care, result in payment that is higher than the global surgery allowed amount). A/B MACs (B) do not attribute such reductions to medical review savings except where the usual medical review process results in recoding of a service, and the recoded service is included in the global surgery package. The maximum a nonparticipating physician may bill a beneficiary on an unassigned claim for services included in the global surgery package is the limiting charge for the surgical procedure.

In addition, the limitation of liability provision (§1879 of the Act) does not apply to these determinations since they are fee schedule reductions, not denials based upon medical necessity or custodial care.

Claims for surgeries billed with a “-22” or “-52” modifier, are priced by individual consideration if the statement and documentation required by §40.2.A.10 are included. If the statement and documentation are not submitted with the claim, pricing for “-22” is it the fee schedule rate for the same surgery submitted without the “-22” modifier. Pricing for “-52” is not done without the required documentation.

Separate payment is allowed for visits and procedures billed with modifier “-78,” “-79,” “-24,” “-25,” “-57,” or “-58.” Modifier “-24” must be accompanied by sufficient documentation that the visit is unrelated to the surgery. Also, when used with the critical care codes, modifiers “-24” and “-25” must be accompanied by documentation that the

critical care was unrelated to the specific anatomic injury or general surgical procedure performed.

A/B MACs (B) do not allow separate payment for evaluation and management services furnished on the same day or during the postoperative period of a surgery if the services are billed without modifier “-24,” “-25,” or “-57.” These services should be denied. A/B MACs (B) do not allow separate payment for visits during the postoperative period that are billed with the modifier “-24” but without sufficient documentation. These services should also be denied. Modifier “-24” is intended for use with services that are absolutely unrelated to the surgery. It is not to be used for the medical management of a patient by the surgeon following surgery. Recognize modifier “-24” only for care following discharge unless:

*The care is for immunotherapy management furnished by the transplant surgeon;

*The care is for critical care for a burn or trauma patient; or

*The documentation demonstrates that the visit occurred during a subsequent hospitalization and the diagnosis supports the fact that it is unrelated to the original surgery.

A/B MACs (B) do not allow separate payment for an additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior procedure and if billed without modifier “-58,” “-78,” or “-79.” These services should be denied.
Codes with the global surgery indicator of “XXX” in the MFSDB can be paid separately without a modifier.

B.Claims From Physicians Who Furnish Less Than the Global Package (Split Global Care)

For surgeries performed January 1, 1992, and later, that are billed with either modifier “-54” or “-55,” A/B MACs (B) pay the appropriate percentage of the fee schedule payment. Fields 17-19 of the MFSDB list the appropriate percentages for pre-, intra-, and postoperative care of the total RVUs for major surgical procedures and for minor
surgeries with a postoperative period of 10 days. The intra-operative percentage includes postoperative hospital visits.

Procedures with a “000” entry in Field 16 have an entry of “0.0000” in Fields 17-19. Split global care does not apply to these procedures.

A/B MACs (B) multiply the fee schedule amount (Field 34 or Field 35 of the MFSDB) by this percentage and round to the nearest cent. Assume that a physician who bills with a “-54” modifier has provided both preoperative, intra-operative and postoperative hospital services. Pay this physician the combined preoperative and intra-operative portions of the fee schedule payment amount.

Where more than one physician bills for the postoperative care, A/B MACs (B) apportion the postoperative percentage according to the number of days each physician was responsible for the patient’s care by dividing the postoperative allowed amount by the number of post-op days and that amount is multiplied by the number of days each physician saw the patient.

EXAMPLE

Dr. Jones bills for procedure “42145-54” performed on March 1 and states that he cared for the patient through April 29. Dr.  Smith bills for procedure “42145-55” and states that she assumed care of the patient on April 30. The percentage of the total fee amount for the postoperative care for this procedure is determined to be 17 percent and the length of the global period is 90 days. Since Dr. Jones provided postoperative care for the first 60 days, he will receive 66 2/3 percent of the total fee of 17 percent since 60/90 = .6666. Dr. Smith’s 30 days of service entitle her to 30/90 or .3333 of the fee.

6666 x .17 = .11333 or 11.3%; and

3338 x .17 = .057 or 5.7%.

Thus, Dr. Jones will be paid at a rate of 11.3 percent (66.7 percent of 17 percent). Dr. Smith will be paid at a rate of 5.7 percent (33.3 percent of 17 percent).

C.Payment for Return Trips to the Operating Room for Treatment of Complications

When a CPT code billed with modifier “-78” describes the services involving a return trip to the operating room to deal with complications, A/B MACs (B) pay the value of the intra-operative services of the code that describes the treatment of the complications.
Refer to Field 18 of the MFSDB to determine the percentage of the global package for the intra-operative services. The fee schedule amount (Field 34 or 35 of the MFSDB) is multiplied by this percentage and rounded to the nearest cent.

When a procedure with a “000” global period is billed with a modifier “-78,” representing a return trip to the operating room to deal with complications, A/B MACs
(B) pay the full value for the procedure, since these codes have no pre-, post-, or intra- operative values.

When an unlisted procedure is billed because no code exists to describe the treatment for complications, A/B MACs (B) base payment on a maximum of 50 percent of the value of the intra-operative services originally performed. If multiple surgeries were originally performed, A/B MACs (B) base payment on no more than 50 percent of the value of the intra-operative services of the surgery for which the complications occurred. They multiply the fee schedule amount for the original surgery (Field 34 or 35) by the intra- operative percentage for the procedure (Field 18), and then multiply that figure by 50 percent to obtain the maximum payment amount.


[.50 X (fee schedule amount x intra-operative percentage)]. Round to the nearest cent.

If additional procedures are performed during the same operative session as the original surgery to treat complications which occurred during the original surgery, A/B MACs (B) pay the additional procedures as multiple surgeries.  Only surgeries that require a return to the operating room are paid under the complications rules.

If the patient is returned to the operating room after the initial operative session, but on the same day as the original surgery for one or more additional procedures as a result of complications from the original surgery, the complications rules apply to each procedure required to treat the complications from the original surgery. The multiple surgery rules would not also apply.

If the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for multiple procedures that are required as a result of complications from the original surgery, the complications rules would apply. The multiple surgery rules would also not apply.

If the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for bilateral procedures that are required as a result of complications from the original surgery, the complication rules would apply. The bilateral rules would not apply.