When an EM service occurs during a postop global period for reasons unrelated to the original procedure, use this modifier.
Question: If the cardiologist performs a pacemaker insertion in the hospital and later visits the patient in observation, should I code the observation visit?
Georgia Subscriber
Answer: You should not charge this visit separately. Pacemaker insertion code 33208 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial and ventricular) has a 90-day global period.
For payers applying Medicare rules, that means that payment for the pacemaker insertion service includes the following services (among others) for 90 days following the procedure:
- Services related to complications following surgery, not requiring additional trips to the operating room
- Postoperative visits (follow-up visits) related to recovery from the surgery
- Postsurgical pain management by the surgeon.
FYI: Medicare specifies certain visits that are not included in the global package, meaning you may report them separately:
- Visits unrelated to the diagnosis that prompted the surgical procedure (unless the visits occur due to complications)
- Treatment for the underlying condition or an added course of treatment which is not part of normal surgery recovery
- Diagnostic tests and procedures
- Clearly distinct surgical procedures which are not re-operations or treatment for complications
- Treatment for complications which requires a return trip to the operating room.
When an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code.
Source: You can find the definition of the global surgical package in Medicare Claims Processing Manual, Chapter 12, Section 40.1.A.
@ Cardiology Coding Alert. Editor: Deborah Dorton, JD, MA, CPC
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The answer hinges on the urologist’s interpretation.
Question: A patient had a robotic prostatectomy for prostate cancer on Jan. 1. Then the patient started experiencing voiding problems in February. At that time my doctor did a cystoscopy to check for bladder neck contracture, which he didn’t find. Is this a new problem? How should I code the second procedure?
Virginia Subscriber
Answer: You’ll have to discuss the procedure with your urologist to see if he considers the voiding dysfunction to be a new problem or a complication of the radical surgery.
Option 1: If the voiding trouble is a new problem, you should report the cystoscopy within the global of the radical prostatectomy using modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). So you will report 52000-79 (Cystourethroscopy [separate procedure]) for both Medicare and commercial payers. The diagnostic code should represent the symptom(s) that led to the cystoscopic examination.
Option 2: If your urologist feels that the problem with voiding is a complication of the surgery, your coding will depend on the payer and the location where the cystoscopic examination took place.
If the patient has Medicare coverage and your urologist performed the cystoscopy in the hospital operating room, then bill the cystoscopy with modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period). If this Medicare patient underwent the cystoscopic examination in the office, most Medicare carriers would not reimburse for this procedure.
For private payers, bill for an in-office cystoscopy with modifier 79 as mentioned above, even if you feel this is a complication. Most commercial and private payers will reimburse for the procedure performed in the global of the radical prostatectomy, and will pay (no matter the location) for any problems after surgery that prevent a smooth uncomplicated surgical convalescence and postoperative care.
@ Urology Coding Alert
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Tip: Make sure the ICD-9 coding & documentation support follow-up visits after the global.
Question: Code 19101 has a 10-day global period, which means you cannot bill an E/M for anything related to that procedure within that time frame. If the patient continues to have follow-up visits outside the global period, should we then report the appropriate E/M level?
Example: Patient has an open breast biopsy on June 15, so the global period goes through June 25. The patient then has additional follow-up visits on June 26, July 3, and July 10. What is the most appropriate way to bill for the three follow-up visits that the surgeon provides outside the global period? Does modifier 24 apply?
Answer …
Answer: You are correct that 19101 (Biopsy of breast; open, incisional) has a 10-day global period. You should code each of the medically necessary office visits (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient …) that the surgeon provides outside the 10-day global period. You do not need to append a modifier.
You do need a modifier, however, when you have a patient visit during the global period that is separate and distinct from the expected post-procedural follow-up.
Then you should use modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).
Be prepared for the insurer to question why so many additional post-procedural visits are necessary. Make sure that the ICD-9 coding reflects any complications, such as infection (998.59, Other postoperative infection), that explain the unusual volume of follow-up visits.
Caution: Before billing the first non-included E/M service on June 26, make sure that extenuating circum-stances did not push the visit into a billable period. For instance, was the 25th a Sunday and you didn’t have any office hours until the 26th? Or did your office have no visits available on the 25th or before, so the patient was forced to come in after the global period ended? If scheduling gamed the system, you should include the visit on the 26th in the global period for 19101.
You can separately bill the appropriate E/M level for the visits on July 3 and July 10.
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If you don’t want federal auditors to come knocking, it’s more important than ever not to code and bill services separately if they should be in the global period. But an overly cautious approach could hurt your bottom line. Learn the rules and get all the reimbursement you deserve at this audio conference.
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MACs are looking for ‘red flags’ to halt additional global period pay
Billing for additional services during a global surgery period is always tricky, but now you can expect special scrutiny for modifier 79 claims.
After the OIG got wind of fraudulent surgery billing with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period), CMS contractors have been on the hunt for modifier 79 abuse. Implement our expert tips below to keep your 79 claims clean.
Obey Global Package Model
The starting point for clean modifier 79 claims is not breaching the global surgical billing concept. Once you understand the global package rules, you’ll know when you have an exception that warrants an additional claim with an appropriate modifier.
Know what’s included: The global package includes the preoperative visit the day before surgery, intraoperative services, postsurgical complications, and postoperative visits during the global period. It also includes post-surgical pain management services by the surgeon, and miscellaneous services such as dressing changes, suture removal, staples, etc., according to Donna Pisani, provider outreach and education consultant with National Government Services (NGS) during a global surgery conference call. NGS is a Medicare payer in 25 states.
Choose 79 for Distinct Procedure During Global Period
If your surgeon performs a service during the global period that the “package” doesn’t include, you can bill separately for the additional procedure — but you’ll have to use a modifier.
Key to 79: You’ll know that 79 is the correct modifier if the second procedure is for an unrelated condition during the global period of the first surgery. In other words, if the same surgeon must perform a separate, unrelated procedure for an unexpected medical condition during theglobal period of a previous procedure, you should append modifier 79 to the subsequent procedural code(s).
Tip: “If the second procedure takes place on a different body part, 79 is usually the correct modifier,” says Joseph A. Lamm, office manager for Stark County Surgeons in Massillon, Ohio.
Another clue that you should use 79 is if the surgeon links a second procedure to a totally different diagnosis and does not mention a “complication” or that the second procedure is staged or related to the first, according to Lamm.
Example: The patient is in the global period for a partial mastectomy (19301, Mastectomy, partial [e.g.,lumpectomy, tylectomy, quadrantectomy, segmentectomy]). During that time, the patient has an appendectomy (such as 44970, Laparoscopy, surgical, appendectomy) because of acute appendicitis. You should append modifier 79 tothe appendectomy code.
Scrutinize Your 79 Claims — Before Your Contractor Does
Thanks to abusive practices of some providers who used modifier 79 to bypass surgical bundling rules, the Office of Inspector General (OIG) “has asked all contractors to look at codes with modifier 79,” Pisani says.
Loophole: Although CMS established pre-payment edits to detect when providers unbundle services from the global surgical package, services billed with modifier 79 were excluded from those pre-payment edits. That’s why CMS has instructed contractors to “strengthen program safeguards” against fraudulent 79 claims.
“Be aware if you’re using modifier 79 that you’re using it appropriately, and your records reflect the documentation,” Pisani notes.
Resource: To read the CMS instruction on modifier 79 scrutiny, go here.
Distinguish Other Global Period Modifiers: Unrelated conditions aren’t the only reason your surgeon might perform a separate procedure during a global surgical period. If the second procedure is not unrelated to the initial surgery, you’ll have to turn to modifiers other than 79.
• Identify planned or staged: Call on modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) when the surgeon performs a secondary surgery during the post-op period of another surgery and the subsequent procedure was planned or staged, Pisani notes.
• Distinguish related but not planned: Modifier 78 (Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postop period) applies to the service when the physician has to unexpectedly return the patientto the operating room (OR) for a related procedure during the postoperative period, Pisani says.
Remember OR restriction: Medicare will only pay for treating a complication during the surgical global period if treatment requires a return to the operating room. Modifiers 58 and 78 do not apply if the Medicare beneficiary does not return to the OR.
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When an EM service occurs during a postop global period for reasons unrelated to the original procedure, use this modifier.
