Surgical Procedure Global Periods
A certain amount of pre-operative and post-operative care is required whenever an invasive procedure is performed. For example, prior to a percutaneous procedure (coronary angiography/intervention, electrophysiology procedure, or peripheral vascular angiography/intervention) the doctor will interview the patient to make sure that they have not eaten anything since the night before and perform an examination to make sure that the patient is not dangerously hypertensive – each of these variables may cause the doctor to postpone the procedure. After the procedure, the doctor will observe the patient to make sure that he recovers from sedation and that hemostasis is obtained (by placing manual pressure or a closure device at the access site). Major surgical procedures (pacemaker and defibrillator surgery) involves a similar pre-operative assessment and a more extensive post-operative follow-up that typically includes discharge from the hospital and an assessment of the incisional site ten days after the procedure.
Medicare and many other payers have established that the reimbursement they issue for the surgical procedure includes the routine pre-operative and post-operative care required for the procedure. For percutaneous procedures, payers consider the pre and post-op care provided on the calendar day of the procedure to be routine. For major surgical procedures, they assert that the pre-operative care provided on the day of and day before the procedure are considered to be compensated by their payment of the procedure. For these pacemaker and defibrillator surgeries, payers also consider the routine post-op care provided in the 90-day period following the surgery to be considered to be reimbursed by their payment.
The span of time in which these routine pre and post-op services are considered to be included in the surgical reimbursement are called “global periods.” Some confusion is caused by the terms Medicare has assigned to the global periods for percutaneous and major surgical procedures. The calendar day of a percutaneous procedure is effectively a one day long global period – Medicare refers to this as a “Zero-Day Global Period.” The global period that applies to major surgical procedures is 92 days long – Medicare refers to it as a “90-Day Global Period.” Services rendered outside the Zero-Day or 90-Day Global Periods are separately billable and payable as long as they are medically necessary. Similarly, services that are not routine pre-op or post-op care are separately billable and payable even when provided within the Global Period. We just need to report that the service is not routine pre-op or post-op care by affixing the appropriate modifier to the visit code. The modifiers to choose from: 24, 25, 57, and 78.
According to the Medicare Claims Processing Manual, preoperative visits after the decision for the procedure is made are considered routine pre-operative care and not separately billable. For most procedures, this limitation prevents us from receiving compensation for visits (admit vs. follow-up visit) on the day of a percutaneous procedure and on the day of, or day before, a pacemaker or defibrillator surgery. The overwhelming majority of invasive procedures are scheduled in advance during a previous patient encounter. For example, most patients who have a heart catheterization are worked up for days or weeks prior to the procedure: they present to the physician with symptoms that trigger non-invasive diagnostic testing like EKGs, echocardiograms, and nuclear imaging. If these tests do not effectively rule out a cardiac etiology for the patient’s symptoms doctors frequently recommend a heart catheterization - the most definitive way to assess the coronary arteries and the function of the heart: wall motion, ejection fraction, valvular function, etc.. When the patient presents to the catheterization lab for the test the doctor will perform a brief interview, conduct a physical examination, and confirm that it is safe to go ahead with the heart catheterization. This is a pre-operative visit rendered after the decision for the procedure was made and it should not be separately reported – even if the doctor dictates a complete history and physical because the facility requires him to.
Sometimes, patients come to the hospital under more dire conditions. For example, a patient may come into the emergency room via ambulance after having syncope. After receiving the request for a consultation from the Emergency Department physician, an electrophysiologist conducts his first history and physical of the patient. An EKG performed in the Emergency Department reveals that the patient is having bouts of sustained ventricular tachycardia and the doctor recommends that the patient has a defibrillator implanted as soon as possible. After discussing the risks and benefits of the procedure with the patient the implant is scheduled for, and implanted, later on the same day. While the EP consultation was rendered within the pre-operative portion of the 92 day global period, it was not a preoperative visit “after” the decision for the procedure is made; it was a problem oriented visit “during which” the decision for the procedure was made. Because of this, the visit is separately billable and payable.
The Medicare Claim Processing System will permit compensation for this visit in which the decision for the implant was made as long as we notify them that this visit is the visit during which the decision for the implant was made. This is facilitated by affixing the 57 modifier to the visit code supported by the doctor’s report: Consultation, Admission, or Follow-Up Visit. According to the National Correct Coding Initiative Policy Manual, “If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier -57. Other E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.” For most cardiology groups, pacemaker and defibrillator surgeries are the only “major” surgical procedures as defined by Medicare.
The National Correct Coding Initiative Policy manual also addresses scenarios in which visits are separately reportable during the pre-operative portion of minor surgical procedures (heart catheterization, peripheral vascular procedures, and electrophysiology studies). For these procedures, the policy manual states, “If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier -25.”
The significance and separate identify of a visit on the day of a minor surgical procedure can only be established by a visit note that details the history, physical examination, diagnostic testing, and assessment/plan associated with a typical patient encounter. In contrast, if the only available documentation is comparable to what would be generated on the same day as an elective/scheduled procedure it probably will not suffice. The visit note must establish that a “significant and separately identifiable E&M service” was provided. The manual also establishes that the note must establish that the E&M service was “unrelated to the decision to perform the minor surgical procedure.”
Since Recovery Audit Contractors are substantially incentivized to find errors with the way physicians bill services, the required for the visit to be “unrelated to the decision” could become problematic for many providers. While there is not a list of buzzwords that will definitively support that the visit was unrelated to the decision for the procedure, it would be beneficial if the visit note clearly illustrates that the visit was focused on assessing signs and symptoms that the patient had and that after a complete workup was performed the doctor made the decision to proceed with the procedure. The performance or consideration of diagnostic testing between the initial patient presentation and the decision for the procedure would further support that the visit was distinct from the decision to perform the procedure.
The management of complications that do not require a return to the operating room and follow-up visits related to recovery from the surgery are compensated by the surgical fee if they are services that take place within the post-operative portion of the “Zero” or “90” Global Periods. For most percutaneous procedures this is limited to a post-op access site evaluation, confirmation that the patient recovers from anesthesia, and provision of the required discharge services. For pacemaker and defibrillator surgeries, doctors typically perform an office-based inspection of the incision site a week and a half after the surgery. This is typically the only post-discharge care required that is related to recovery from the surgery and it should not be reported a problem oriented established patient office visit. Some organizations choose to credit physicians for these follow-up visits and keep track of them by reporting the incisional site check with CPT code 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure). While Medicare does not compensate for this code, you may find that some payers do.
If the doctor identifies an infection at the time of the incisional site check it might be managed in the office or it might require the doctor to take the patient back to the lab to open and irrigate the pocket. If the infection is managed in the office it is not payable, if it is a complex infection it may need to be addressed in the operating room – these procedures are separately billable with code 10180 (Incision and drainage, complex, postoperative wound infection). Sometimes the patient has a hematoma (a collection of blood at the incisional site) that needs to be drained in the operating room; rather than reporting these as an inflectional incision and drainage, it is more appropriate to use code 10140 (Incision and drainage of hematoma, seroma or fluid collection). However, in either case it is appropriate to attach the 78 modifier to the surgical code. Modifier 78 is defined as “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.”
Many patients who receive pacemakers and defibrillators have several active medical conditions that are managed by the implanting physician. Some of these conditions will be unrelated to the condition that necessitated the implant, others are be directly related. Whenever doctors provide medically necessary follow-up visits for these conditions they will be separately payable – even if they are provided during the post-operative 90 days. A common example of this is a patient who has a bi-ventricular defibrillator implanted because they have heart failure, a reduced ejection fraction, and non-ischemic dilated cardiomyopathy. After the device is implanted the patient’s left ventricle reverse remodels (a term used to describe the heart going back to its normal size and shape because of the bi-ventricular pacing). Reverse remodeling increases cardiac output, improves the patient’s quality of life, and frequently requires adjustments to the patient’s complex medical regimen. In order to assess the patient’s status and manage their heart failure a fairly extensive office visit is medically necessary. This office visit is not-uncommonly performed before the end of the 90 Day Global Period and it is separately billable.
To secure payment for medically necessary follow-up visits during the 90 Day Global Period that are not routine post-operative recovery it is necessary to attach the 24 modifier to the office visit. This modifier is defined as “Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period.” Without the 24 modifier Medicare will deny the office visit as being routine post-operative care; the claim processing system is set to automatically consider all post-op visits in the 90 day period as routine care – it is up to us to inform them that it is unrelated to the routine post-operative recovery.
Understanding the quirky Global Period rules is necessary if you wish to secure appropriate payment for services rendered. In many cases, the difference between payment and denial is nothing more the application of one of the modifiers featured in this article. However, keep in mind that pre-operative and post-operative visits should only be reported if they are medically necessary and the modifiers should only be reported when they accurately describe the applicable exception as defined by the afore mentioned Medicare policies. Practices that routinely report E&M services on the same day as scheduled/elective surgical procedures are low hanging fruit for RAC auditors. Also, practices who do not report services that are not officially included in the Global Period can forfeit considerable amounts of earned revenue. The financial and regulatory pressures of the current healthcare system dictate accuracy (not aggressiveness or conservatism) with coding issues.