Insurance companies classify surgical procedures as either minor or major.
Minor procedures have:
- Zero or 10 days of postoperative care for Medicare and
- Zero, 10 or 15 days of postoperative care for non-Medicare payers.
Major procedures have:
- 90 days of postoperative care for Medicare and
- 45, 90 or 120 days of postoperative care for non-Medicare payers.
Field 16 of the Medicare Fee Schedule Data Base provides the postoperative periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with entries of 000, 010, 090, XXX, YYY and ZZZ:
- Codes with “000” or “010” are either minor surgical procedures or endoscopies.
- Codes with “090” are major procedures.
- Codes with “XXX” indicate that the global concept does not apply.
- Codes with “YYY” are unlisted procedure codes and the carrier determines whether the global concept applies and establishes postoperative period, if appropriate, at the time of pricing.
- Codes with “ZZZ” are add-on surgical codes that are always billed with another service. There is no postoperative work included in the fee-schedule payment for the ZZZ codes. Carriers will pay for both the primary and the add-on codes and apply the global period assigned to the primary code.
To see how this works, consider this case study: Performance of backbench preparation of corneal endothelial allograft prior to transplantation associated with endothelial keratoplasty.
CPT code 65756-RT or -LT (090)
Add-on code +65757-RT or -LT (ZZZ)
Diagnosis code 371.57 Fuch’s endothelial dystrophy
While Medicare publishes the postoperative days, commercial plans generally do not. Therefore, it is also a good idea to ask for the global period for the procedure(s) being performed when calling non-Medicare payers to obtain prior authorization.
Note: Category III codes such as 0253T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space are not assigned global surgical postoperative days. In these cases, it is appropriate to charge for subsequent visits and collect the proper copayment for each return visit formerly considered “postoperative” unless the payer specifies otherwise. Category III codes have an XXX global surgical indicator.
To determine the global period for minor procedures, carriers count the day of surgery and the appropriate number of days immediately following the date of surgery.
Example (procedure with 10 follow-up days):
- Date of surgery: Jan. 5
- Last day of postoperative period: Jan. 15
To determine the global period for major surgeries, carriers count one day immediately before the day of surgery, the day of surgery and the 90 days immediately following the day of surgery.
- Date of surgery: Jan. 5
- Preoperative period: Jan. 4
- Last day of postoperative period: April 5
What’s Included in the Global Surgical Package?
The following services are included in the global surgical package when provided by the surgeon:
- Preoperative visits beginning with the day before the day of surgery and the day of surgery, unless it is the visit to determine the need for surgery;
- Intraoperative services that are typically necessary and a usual part of the surgical procedure;
- Complications following surgery unless it is necessary to return to the operating room or dedicated procedure room;
- Postoperative visits during the duration of the postoperative time;
- Visits in the hospital;
- Visits in ASCs; and
- Visits for critical care services.
Example #1: If performance of a YAG laser capsulotomy is necessary within the postoperative period of a cataract surgery on the left eye, correct coding would be CPT code 66821-78-LT, indicating that a return to the operating or dedicated procedure room for a related procedure is required.
Example #2: The patient requires laser suture lysis during the postoperative period. Suture removal, by any method, during the postoperative period is not separately payable in any location (e.g., exam lane, dedicated laser suite, ASC or hospital outpatient department).
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About the author: Sue Vicchrilli, COT, OCS, is the Academy's coding executive, the author of EyeNet's “Savvy Coder” and AAOE's Coding Bulletin, the Ophthalmic Coding Coach, and the Ophthalmic Coding Series.