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Surgical Package FAQ

What is included in CPT's surgical package?

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:

  • 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)

Intraoperative service:

  • Actual performance of the surgical procedure

Postoperative services:

  • Immediate postoperative care, including dictation, postoperative notes, talking with the family and other physicians
  • Writing orders
  • Evaluating the patient in the post-anesthesia recovery area
  • Typical uncomplicated post-operative care 

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. It currently includes:

  • All additional medical or surgical services required of the practitioner unrelated 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.
  • 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.

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

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.

  • -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.

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

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.

Complete 2023 List of Codes and Additional Information

Can I bill for postoperative suture removals for Medicare patients?

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:

  • 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/M 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.

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:

  • 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.
  • See FAQ 5 above for additional follow-up care information pertaining to Medicare. 

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.

Can I bill for other nerve blocks or trigger point injections?

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. 

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

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.

https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched

Updated March 2023

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors, or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising from the use of such information or material. Specific coding or payment-related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director, at (469) 499-0133 or dmckenzie@acep.org

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