Surgical Package FAQ

FAQ 1.  What is included in CPT's surgical package?

The global surgical package concept includes the pre-operative, intra-operative and post-operative services, and are considered included in the specific CPT code.

The pre-operative stage includes:

Local infiltration

Metacarpal/metatarsal/digital block

Topical anesthesia

Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior or on the date of the procedure (history and physical)

Intra-operative service:

Actual performance of the surgical procedure

Post-operative services:

Immediate postoperative care, including dictation, post-operative notes, talking with the family and other physicians

Writing orders

Evaluating the patient in the post-anesthesia recovery area

Typical uncomplicated post-operative care 

FAQ 2.  What is included in Medicare's surgical package?

Medicare's Pre-op and Intra-op definitions mirror CPT.  However, the CMS definition of Post-operative services differs from CPT and is more expansive and includes:

All additional medical or surgical services required of the practitioner to complications, which do not require additional trips to the operating room;

Follow-up visits that are related to recovery from the surgery;

Post-surgical pain management;

Supplies, except for those identified as exclusions; and

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.

FAQ 3.  Can an E/M be billed with a procedure according to CPT guidelines?

CPT states that "subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (history and physical)" is bundled with the procedure.  However, an E/M service that takes place prior to the decision for surgery or the E/M service at which the decision for surgery is made is not bundled.  For example, a patient with a finger laceration presents to the ED.  Because patients do not present with a request for a single layer repair of a finger laceration, physicians must perform an appropriate E/M prior to deciding if an intervention, surgical or otherwise, is appropriate.  At absolute minimum, an EMTALA required medical screening exam must be performed.  

Determination of appropriate surgical management included in the non-bundled E/M service would involve taking a history regarding the overall condition of the patient, time since and mechanism of injury, checking meds/allergies/tetanus status, looking for co-morbidities affecting treatment (such as diabetes or a renal failure), screening for other injuries, and determining what, if any procedure needs to be done.  An E/M service that represents a separately identifiable service (e.g., to rule out additional injuries, screening for physiologic etiology, or manage an illness) can always be reported with a procedure.  If, however, performance and documentation only addresses the surgical procedure and does not provide an overall evaluation of the patient's condition, history of injury, review of related and/or additional systems, comorbidities, allergy status and management options, only the surgical procedure may be reported.

FAQ 4.  Under CPT coding principles what modifier can be placed on the E/M when reported with a procedure?

For CPT coding and depending upon a payer's requirements, if the treating practitioner deems that the work associated with making the decision for surgery (e.g., precise assessment of associated other damage, what type of procedure, etc). warrants an E/M, then the E/M may have the -57 modifier appended to reflect that this service resulted in the decision to perform surgery.  The diagnosis could be the same for the E/M and the surgical procedure.

If a separate, identifiable E/M service is provided then an E/M level can be coded to reflect this service.  In this latter case, again depending upon a payer's requirements, the -25 modifier (rather than the -57 modifier) may be appended to the E/M level to indicate that this was a service separate from the surgical procedure.  The diagnosis for the respective E/M and surgical services could be the same or different depending on the circumstances.

In the situation where a -25 modifier and a -57 modifier might seem appropriate to use together, CPT requires that only the single most appropriate modifier be reported.  Unfortunately, in the ED setting, payers tend to more easily acknowledge the -25 than the -57 modifier.

-25 Modifier
Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

-57 Modifier
Decision for surgery: An evaluation and management service that resulted in the initial decision to perform the surgery.

FAQ 5.  Does Medicare add any other guidelines with respect to surgical procedures?

 Medicare differentiates between major and minor procedures.

The surgical package for major surgical procedures (those with a global period greater than 10 days), does not include "the initial consultation or evaluation by the surgeon to determine the need for surgery." Therefore, for Medicare, the -57 modifier can only be appended to an E/M service to reflect the work performed to determine the need for major surgical procedures.

In order to code an E/M service in conjunction with minor surgical procedures (those with 0-10 day global period), a medically necessary "significant, separately identifiable service" must be performed in addition to the surgical procedure.  In this case, the -25 modifier is appended to the E/M level to indicate the performance of a separate service.  This "separate service" requirement is not the same as "the decision for surgery" service provided in conjunction with a major procedure.  Regarding minor procedures, the Medicare Carriers Manual section 4821 states, "Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.  For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.  As the "need for surgery" concept does not apply for minor procedures, it is not appropriate to use the -57 modifier and in this case the -25 modifier would be the correct choice, presuming that all the -25 requirements are satisfied.

Effective January 1, 2011, Medicare eliminated the 10 day global period for simple wound repairs (CPT 12001-12018).  Follow-up visits and suture removal codes should be assigned as appropriate.

FAQ 6.  Can I bill for postoperative suture removals for Medicare patients?

For Medicare, suture removal for simple laceration repairs is no longer bundled into procedure codes 12001-12018.  Follow-up visits and suture removal charges may be assigned as appropriate.  However, since the patient may be required to pay a "co-pay", the decision to bill Medicare patients for suture removal depends upon your group's philosophy.  (Remember, for payers adhering to CPT coding principles, suture removal is included in the surgical package as typical uncomplicated post-op care).

FAQ 7.  Under CPT, can I bill for follow-up care and wound checks?

In general, post-operative follow-up care is divided into two separate categories:

  • Follow-up Care for Diagnostic Procedures which includes only the care related to recovery from the diagnostic procedure itself and does not include the condition for which the procedure was performed or any other concomitant conditions.
  • Follow-up Care for Therapeutic Surgical Procedures which includes only that care which is usually a part of the surgical service.

CPT bundles "typical post-operative care" into the procedure. Most likely, "typical" will have to be assessed on a case-by-case or group by group basis. Wound checks two days after an "I & D" or repair of a contaminated laceration may or may not represent "typical care" and reporting of appropriate E/Ms may still apply. Packing removals may represent "typical care", as the packing removal is an inherent and expected component of the original Incision and Drainage. Complications such as infection or would dehiscence exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services are separately reportable.  

FAQ 8.  Under Medicare, can I bill for follow-up care and wound checks?

In general, post-operative follow-up care is divided into two separate categories:

  • Follow-up Care for Diagnostic Procedures which includes only the care related to recovery from the diagnostic procedure itself and does not include the condition for which the procedure was performed or any other concomitant conditions.
  • Follow-up Care for Therapeutic Surgical Procedures which includes only that care which is usually a part of the surgical service.

For Medicare, wound checks following simple wound repairs (CPT 12001-12018) are separately billable beginning the day after the procedure because the global period for these procedures is zero days.

For Medicare, complications which occur during the global period and do not require additional trips to the operating room are not separately reportable.  However, for Medicare, complications following simple wound repairs (CPT 12001-12018) would be separately reportable beginning the day after the procedure because the global period for these procedures is zero days.

FAQ 9.  Can I bill for digital blocks?

For payers following CPT guidelines, these services are not separately reimbursed when performed in conjunction with a surgical procedure.  They are clearly bundled as part of the global surgical package as outlined in the CPT introduction to the surgical section.  Under Medicare's global service package rules, digital blocks have always been bundled when performed in conjunction with another procedure. Digital blocks performed in the absence of a procedure (i.e. for pain control alone) remain billable for both Medicare and CPT.

 FAQ 10.  Can I bill for other nerve blocks?

The most common nerve block that might be billed independent of a surgical procedure is the dental block.  Dental, femoral, and hematoma blocks are common separately billable ED procedures and could be reported in addition to an E/M level.

FAQ 11.  How do I find the Medicare surgical period for a CPT/HCPCS code?

CMS now has a searchable database on its website www.cms.gov under physician fee schedule and a good Medicare newsletter on the Global Surgery Period can be found here: 

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf.

Last Updated 04/2014

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