Editor’s note: This article builds on last month’s introduction to surgical coding fundamentals, which covered what’s included in the global surgical package. We’ll continue the series next month with a look at surgical modifiers.
If medically necessary and appropriately documented, the following services — which are not included in the global surgical package — may be billed separately:
- The initial exam by the surgeon to determine the need for major or minor surgery.
- New patient exams do not require the use of modifier –57 (office visit to determine the need for a major surgery) or modifier –25 (significant, separately identifiable evaluation and management service indicating the need for a minor surgery to be performed).
- Visits unrelated to the diagnosis for which the surgical procedure is performed.
- Treatment for the underlying condition or an added course of treatment that is not part of the recovery from surgery.
- Diagnostic tests and procedures, including diagnostic radiological procedures.
- Example: IOL calculations in a patient who is in the global postoperative period of a glaucoma procedure.
- Clearly distinct surgical procedures that are not reoperations or treatment for complications.
- Example: Cataract surgery in the right eye during the global postoperative period of the left.
- Treatment for postoperative complications that require a return trip to the OR.
- An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a laser or endoscopy suite. It does not include a patient’s room, a recovery room or an intensive care unit, unless the patient’s condition was so critical that there would be insufficient time for transportation to the OR.
- A more extensive procedure that is required if a less extensive procedure failed.
- Example: Retinal detachment repair after an unsuccessful focal laser treatment for horseshoe tear.
- Individual and separate procedures that are to be performed in stages.
- Example: 5FU injections in the lane following a trabeculectomy procedure.
- Minor surgeries unrelated to the major surgery.
- Example: SLT in left eye following a filtering bleb procedure in the right eye.
Concurrent care exists when more than one physician renders services during the postop period in the global surgical service. The reasonable and necessary services of each physician rendering concurrent care are covered when services are medically necessary and each physician plays an active role in the patient’s treatment.
Example: The surgeon seeks the professional opinion and advice of a glaucoma specialist for management of a post-operative intraocular pressure problem.
A provider other than the surgeon can also appropriately bill for services rendered when providing care and treatment in the postoperative period for an underlying condition or medical complication unrelated to the original surgery. This would most often occur when the surgeon and the other physician(s) are in different specialties.
Example: The surgeon requests that a retina specialist manage an underlying diabetic condition in the patient’s other eye.
Concurrent care cases do not include transfers of care because the surgeon is sick, tired or the office is closed. They also do not include standing orders or hospital protocol. In all instances, documentation must support the medical necessity of the second physician’s services. These physician’s services must not be those that would be considered part of the global surgical package.
Documentation that concurrent care is deemed medically necessary during the global period is very important and should demonstrate the following:
- A determination that the patient’s condition warranted the services of more than one physician, and
- Documentation indicating the different specialties of the physicians as well as the patient diagnosis that differs from the preceding surgical diagnosis.
Next month: Surgical modifiers.
Issue Index | Related Articles | YO Info Archive
* * *
About the author: Sue Vicchrilli, COT, OCS, is the Academy's coding executive and the author of EyeNet's “Savvy Coder” column and AAOE's Coding Bulletin, Ophthalmic Coding Coach and the Ophthalmic Coding series. Additional reporting by Kim Ross, OCS, CPC, Academy coding specialist.