Sort Out Surgical Cases

The Hospitalist. 2008 August;2008(08):

August 1, 2008|The Hospitalist

Hospitalists often are involved in the care of a surgical patient. Reimbursement for surgical procedures includes payment for pre-, intra-, and post-operative care.

Knowing the billing and coding responsibilities apart from those of the surgeon is imperative for the hospitalist’s accurate charge capture. There are several critical misconceptions in this regard:

Hospitalists cannot bill for services when involved in a surgical case;
Surgeons are not responsible for inpatient care if the patient is stable and does not require additional inpatient post-op visits; and
Modifiers are not required for hospitalist claims unless the hospitalist reports under the same tax identification number as the surgeon.

Determine Global Period

Procedures are categorized as major or minor surgery. A global period is assigned to each procedure code, designating post-operative periods of zero, 10, or 90 days. Physician services during this global period are considered part of the packaged payment and not separately reimbursed.

The global period for any given CPT code can be identified in the Medicare Physician Fee Schedule and accessed at www.cms.hhs.gov/PfsLookup. In addition to zero, 10, and 90 days, services can be noted with:

XXX, indicating the global period concept does not apply; or
ZZZ, indicating an “add-on” procedure that must always be reported with the relevant primary procedure code; “add-on” procedures assume the global period of the primary procedure.

Major surgery routinely is allotted 90-day global periods. Therefore, the surgeon is responsible for the patient and must provide all related care one day prior to the surgery forward thru 90 postoperative days at no additional charge. Minor surgery, including endoscopy, has zero or 10-day postoperative periods, bundling all services on the surgical day only, or the surgical day and the subsequent 10 days, respectively (see Table 1, p. above).

The Surgeon Defined

Any qualified physician able to perform “surgical” services within his scope of practice is considered a “surgeon” for billing purposes. For example, a pulmonologist, or primary care physician, must meet the surgical billing and documentation requirements when performing bronchoscopies or uncomplicated incision-and-drainage services, respectively.

Surgical services easily are identified as any code included in range 20000-69999. This code series includes major, minor, and endoscopic procedures. The “surgeon” and all physicians in the same group practice (i.e., reporting services under the same tax identification number) with the same specialty designation must adhere to the global period billing rules.

Alternately, physicians with different specialty designations in the same group practice (e.g., multispecialty group that reports services under the same tax identification number) or different group practices can perform and separately report medically necessary services during the surgeon’s global period, as long as a formal (mutually agreed upon) transfer of care did not occur. Information on physician specialty designations is available at www.highmarkmedicareservices.com/partb/refman/appendix-d.html.

Key Modifiers

25: Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.

A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Report this modifier with separately identifiable visits provided on the same day as minor surgical procedures, or endoscopies.

57: Decision for Surgery. An evaluation and management service that resulted in the initial decision to perform the [major] surgery may be identified by adding the modifier 57 to the appropriate level of E/M service. Decisions for elective surgeries are typically made at a previous outpatient encounter. Do not append modifier 57 when this occurs.

24: Unrelated E/M service by the same physician during a postoperative period. The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier 24 to the appropriate level of E/M service.

Modifier 24 is not recognized when appended to postoperative visits provided during the same hospitalization in which the surgery occurred. Append modifier 24 to all unrelated outpatient care, post-discharge, or inpatient care during readmissions within the designated global period. Modifier 24 is only used for visits associated with 10- or 90-day postoperative periods.—CP