The global surgical package concept includes the preoperative, intraoperative and postoperative services, and are considered included in the specific CPT code.
The preoperative stage includes:
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. It currently includes:
CPT states: "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. Evaluation and decision-making for appropriate surgical management 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 address the surgical procedure and do not provide an overall evaluation of the patient's condition, history of injury, review of related and/or additional systems, co-morbidities, allergy status and management options, only the surgical procedure may be reported.
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 readily acknowledge the -25 modifier compared to the -57 modifier.
Medicare differentiates between major and minor surgical 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 a 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, that is, procedures with a 0-10 day follow-up period according to Medicare CMS Transmittal 11195, January 20, 2022, "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 (CPT12001-12018). Follow-up visits CPT codes and suture removal ICD-10 codes should be assigned as appropriate. For intermediate and complex laceration repairs and many other minor surgical procedures, the 10-day follow-up period is still applicable. Check the 2023 National Physician Fee Schedule Relative Value File for post-op values for all codes.
For Medicare, suture removal for simple laceration repair is not 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 copay, the decision to bill Medicare patients for suture removal depends upon your group's philosophy.
Can I bill non-Medicare patients for follow-up care and wound checks?
For payers adhering to CPT coding principles, suture removal is included in the surgical package as typical uncomplicated post-op care. In general, post-operative follow-up care is divided into two separate categories:
Can I bill Medicare patients for follow-up care and wound checks?
In general, post-operative follow-up care is divided into two separate categories:
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.
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. Trigger point injections are separately billable procedures. Check with your Medicare administrator for Local Coverage Determinations (LCD) regarding nerve block and trigger point injections.
CMS now has a searchable database on its website under physician fee schedule and the 2023 National Physician Fee Schedule Relative Value File, January Release, lists global days for every CPT code recognized by Medicare.
Updated March 2023
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