By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement
When a payer reimburses you for surgery, it is paying for something known as the global surgical package. This payment covers the surgery plus certain related services and post-op visits that take place during a set number of days (known as the global period).
When you provide services that aren’t related to the surgery, it’s important to check whether your practice performed them during the procedure’s global period and, if so, whether you can bill for those services separately.
1: Check the Global Period
Minor versus major surgery. Payers classify a surgical CPT code as either minor or major, based on the code’s global period.
For Medicare Part B: Minor procedures have either a 0- or 10-day global period; major procedures have a 90-day global period.
For non-Medicare payers: Minor procedures have either a 0- or 10-day global period; major procedures have a 45-, 60-, or 90-day global period.
Why the global period matters. If a patient encounter took place during the global period, the payer will probably assume that it was postoperative care that was covered by the global surgical package. However, if the patient encounter wasn’t related to the earlier surgery, you would flag that fact by appending a modifier to the CPT code. If you don’t, you won’t get paid.
Which services are part of the global surgical package? Services that are considered to be post-op care include all related exams that are provided to assure good recovery, whether they are performed by the surgeon or another physician within the practice. Post-op care also includes removal of sutures (even if the removal is done by laser), staples, and tubing, as well as additional laser, if the laser is performed in stages.
The post-op care does not include either unrelated exams or related or unrelated tests. It also doesn’t include any return to the operating room or office procedure room for additional surgical procedures, except additional laser (descriptors for laser CPT codes include the phrase “1 or more sessions”).
What if the global period is 0 days? When a procedure has a 0-day global period, you can bill for a return visit if the ophthalmologist determines that follow-up is needed to assure that the eye is healing. An example of a code with a 0-day global period is CPT code 65220 Removal of foreign body, external eye; corneal, with slit lamp.
What if the global period is 10 days? When a minor surgery has a 10-day global period, the payer allowable covers both the initial surgery and payment for the anticipated number and type of post-op visits. Take, for example, the payment for CPT code 68761 Closure of the lacrimal punctum; by plug. This payment amount is based on the assumption that there would be one post-op visit at the level of CPT code 99212, which is the evaluation and management code for an exam of an established patient that involves a straightforward level of decision-making.
How do you know a procedure’s global period? The global period should be posted on the payer’s website or in its fee schedule, but payers don’t always make this information public. For your convenience, the Academy publishes the global periods for federal and commercial payers in Coding Coach: Complete Ophthalmic Code Reference and in Retina Coding: Complete Reference Guide (aao.org/store).
Best practice. On your charge sheet or superbill, indicate next to the CPT codes whether minor surgeries have a 0- or a 10-day global period. Then you won’t have to repeatedly look up a CPT code’s global period.
2: Determine Your Payer’s Documentation Requirements
Many minor surgical procedures have documentation requirements. For example, when you submit CPT code 67028 to bill for an intravitreal injection, payers expect you to meet a long list of documentation requirements (see the checklist at aao.org/retinapm). Note: Documentation requirements for a procedure can vary by payer.
What About Modifier –25 and Minor Surgeries?
Suppose you perform an exam on a patient on the same day that he or she undergoes a minor surgical procedure. If this exam qualifies as being a “significant, separately identifiable service,” you would flag that fact by appending modifier –25 to the exam code.
If you needed to examine the eye to determine whether to perform a minor procedure, the Academy believes that it is appropriate and consistent with CMS regulations to bill the office visit with modifier –25. However, some auditors have insisted that the patient’s charts must document that the fellow eye had disease or that the treated eye had another problem and it was medically necessary to evaluate that eye on the same day. Some practices have reported failing their audits when they lacked that documentation.
You can increase your chance of avoiding an audit failure with comprehensive documentation, including a relevant chief complaint, of the significant, separately identifiable reason for the exam.