Global Period: Reporting Subsequent Inpatient E/M Services Following Surgery

By Michael D. Miscoe, CPC, CHCC

At the recent AAPC National Conference in Anaheim, I was asked an excellent question during ad-hoc networking. The question was, “Is subsequent inpatient E/M services or discharge evaluations following surgery within the global period reportable? If so, what modifier is appropriate?”

Evaluation and Management – CEMC

As is the case with most coding questions, the answer is: it depends. The ability to report subsequent hospital care following surgery is conditional. Let’s look at the scenarios that determine the conditional correct answers, and demonstrate the process for finding them.

To find the answer, you should do the following:

  • Consider who you are billing.
  • Determine if there is a statutory or contractual mandate to follow that carrier’s policies.
  • Search the relevant statute, regulation, policy or contract as appropriate to determine the appropriate rule on the issue if a mandate exists.

In this case, the carrier is Medicare. As a result (whether the provider is participating), we start our research with the National Correct Coding Initiative Policy Manual (NCCIPM) and also check the interpretive guidance published by CMS for a more restrictive position relative to this specific issue. In this situation, we can omit a review of the Medicare statute or regulations as it is unlikely either reference directly addresses this specific issue.

The NCCIPM defines the Medical/Surgical package at Chapter 1, Section C. The NCCIPM clearly indicates, “most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work.” While this section addresses “procedures” considered as part of the post-procedure work, it fails to address the issue of post surgical evaluation and management services. Subsection D of Chapter I addresses evaluation and management (E/M) services, but only focuses on the E/M services performed “on the same date of service as a procedure with a global period of 000, 010, or 090.” The following additional guidance is found:

If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier -57. Other E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable. NCCI does not contain edits based on this rule because Medicare Carriers have separate edits.

NCCIPM, Chapter 1, § D at p. 11.

This section of the NCCIPM is missing the instruction for subsequent E/M services during the global period included in the reimbursement for the surgical procedure.

Chapters III-VIII (relating to the various types of surgical procedures) each address the global period with respect to E/M and replicate the instructions at Chapter I referenced above. Chapter XI addresses E/M services directly and also duplicates the instructions above. As a result, there isn’t a restriction in the NCCIPM for reporting subsequent in-patient E/M services during the global surgical period.

Although no such restriction is apparent in the NCCIPM, before we leap with joy we need to check to see if there is a relevant rule for subsequent in-patient hospital care in CMS’ interpretive guidance. You can find the Medicare reference controlling this issue in the Medicare Claims Processing Manual, Pub 100-4, by simply researching CMS’ interpretive guidance via the internet.

While some familiarity with the Manual system is helpful, the site does provide the capacity to search various Medicare manuals. In this case, Chapter 12 provides the information relevant to our issue.

A. CPT® Modifier “-24”—Unrelated Evaluation and Management Service by Same Physician During Postoperative Period

Carriers pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT® codes 99221-99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT® modifier “-24,” and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure. They do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery. All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment.

Pub 100-4, Ch.12, §30.6.6 A

As a result, when the physician/surgeon evaluates or provides subsequent care for a condition unrelated to the condition requiring surgery, the subsequent care in-patient E/M service may be reported with modifier 24. Since most of us are aware that the reimbursement for the surgical procedure includes the usual post surgical follow-up, this may not come as a surprise. Because there isn’t a general prohibition of reporting E/M services on days subsequent to a surgical procedure (within the global period), CMS provides a specific restriction to subsequent in-patient E/M services during the hospital stay when the surgery is performed and the service is related to E/M of a condition unrelated to the surgery.

Now with a clear understanding of subsequent in-patient E/M services, what about the discharge? Let’s turn to the Medicare Claims Processing Manual again for instructions, specifically:

A. Subsequent Hospital Visit and Discharge Management on Same Day

Pay only the hospital discharge management code on the day of discharge (unless it is also the day of admission, in which case, the admission service and not the discharge management service is billed). Carriers do not pay both a subsequent hospital visit in addition to hospital discharge day management service on the same day by the same physician. Instruct physicians that they may not bill for both a hospital visit and hospital discharge management for the same date of service.

Pub 100-4, Ch. 12 § A

Note: §30.6.6 doesn’t address the discharge at all, and § restricts admission and discharge to occur on the same day. Since the NCCIPM doesn’t include a general prohibition for reporting a subsequent E/M service during the global period, there isn’t a clear restriction for reporting the discharge service unless the discharge occurred either on the same day as the admission, or the same day as the surgical procedure.

While the analysis and answer is relevant to Medicare claims only, I am hopeful the analytical approach and answer can be used to help you develop your own answers related to global period issues.


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