AMA/CPT now Agrees with Medicare and the Global Surgery Package Rules

In a move to finally give direction to an ongoing dilemma on just what is and isn't included in the global surgical package, CPT included new, specific language as to the components of the package. Now this language was added in 2002, but here is a 2005 update to make sure your office would not fall under scrutiny should the rules not be followed. The language is included at the front of the Surgical Guidelines Section of CPT, under the heading "CPT Surgical Package Definition:"

"The services provided by the physician to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. On defining the specific service "included" in a given CPT surgical code, the following services are always included in addition to the operation per se:

Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical)
Immediate postoperative care, including dictating operative notes, talking with the family and other physicians
Writing orders
Evaluation the patient in post anesthesia recovery area
Typical postoperative follow-up care."

E/M encounter is critical change

By far the most significant aspect of the new language is that which relates to the pre-operative E/M visit with history and physical. Prior to this, CPT never specified that any E/M services were included in the surgical package. Now they include an E/M service on the day of or day before surgery, if it relates to the surgery, yet is not the visit at which the decision for surgery was made.

If a physician conducts a history and physical on the patient the day of or the day before surgery, on an inpatient or outpatient basis, the H & P is included in the global charge. Some controversy may occur when the physician does the H & P after the decision to do surgery is made, but does so two or more days prior to the surgery." The CPT guidelines indicate that this visit can be billed outside of the global surgical package, but it remains to be seen whether individual insurance companies will interpret the new guideline in this manner, or not pay for any pre-operative H & P. The physician should still be performing the service in a time frame that is in the best interest of the patient from a clinical perspective. This may mean that the H & P is done a week before surgery." In fact, rather than schedule the H & P two or three days before surgery, providers are wise to schedule the visit a week out, to avoid any ambiguity with the carrier.

E/M and decision for surgery

The new language will also call for coder scrutiny regarding the decision for surgery. The –57 modifier is appended to an E/M visit where the decision for surgery is made, when that visit occurs the day before or the day of surgery. So, for example, if a patient reports either to the office or the hospital with a fractured femur and then the physician immediately takes the patient to the O/R for an ORIF then the –57 modifier can be appended to the e/m service billed. Or another example would be a patient that reported to the E/R for abdominal pain and an e/m was performed that determined the need for an immediate appendectomy. Then a –57 modifier could be reported on the e/m service.

Given the severity of the patientï¿½s condition when the patient presented, the Orthopedist or General Surgeon could still charge for an appropriate level E/M visit (e.g., 99243) with a –57 modifier (decision for surgery) since the surgery was immediate. The E/M encounter with H & P as defined in the new CPT language is bypassed, since an H & P was part of the E/M encounter when the decision for surgery was made." Because the –57 modifier indicates more involved medical decision making on the physicianï¿½s part, the carrier should not take exception to paying for the separate encounter on the same date that the procedure or surgery was performed.

The flipside to the above example occurs if the Orthopedist treats a patient and then schedules surgery more than one day out. For example, a patient reports with a complaint severe knee pain (719.46). The physician examines her during a routine mid-level E/M encounter (e.g., 99213), and then schedules an MRI, to diagnose the problem. The MRI, which takes place at the earliest available appointment three days later, reveals torn medial meniscus (836.0). One week later, the patient undergoes a Arthroscopic Medial Meniscectomy (29881). Prior to the surgery, the physician schedules a visit with the patient a couple of days before surgery and conducts a pre-operative H & P, required paperwork by the hospital and as outlined in the new CPT language. Since the encounter at which the decision for surgery was made previously at the patientï¿½s encounter that was more than a week prior, there is no need for the –57 modifier. Further, was their and no ambiguity in terms of whether another E/M encounter with H & P is required. It was more to touch bases with the patient and fill out that required hospital paperwork. That is not a billable service, unless there were some risk factors that needed to be addressed and treated prior to surgery (i.e. coumadin patient).

Unrelated E/M visits

If the patient is seen on the day before or the day of surgery for a problem unrelated to the reason for surgery, then an E/M service can be billed separately, adding the modifier -25 to the E/M service for a same day procedure or no modifier if the unrelated E/M service occurred on the day before surgery. For instance, the patient has developed a XXXXX the day before an in office or hospital surgical procedure. Rather than schedule a separate visit to discuss the problem, she may wait until the day of the procedure to mention it to the physician. Although the condition is not serious enough to warrant a postponement of surgery, a separate, unrelated E/M visit does occur, and can be billed with the appropriate code (99212-99215) and a -25 modifier for a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.

Article by:
Terry A. Fletcher, BS, CPC, CPC-Cardio, CPC-E/M, CMSCS, CMC, CCS-P, CCS
Healthcare Coding and Management Consultant
AAPC Local Chapters Board of Directors, Executive Chair 2007-2009 (AAPCCA)
27881 LaPaz Road, G156
Laguna Beach, CA 92677
800-805-8056
http://www.TerryFletcher.net

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