Coordinate Physician Billing when Splitting Surgical Package Services

By Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS, CCS-P

The surgical package is a reimbursement concept that bundles all typical care related to a specific surgical service into a single payment. Many surgeons find information about what is bundled confusing, and either inappropriately bundle all of their work into a single payment or bill separately for services that should be included in the package. Even more confusing is when two physicians “split” services bundled into the surgical package. In such cases, careful coordination of billing is necessary.

Define What Is Included

Evaluation and Management – CEMC

CPT® defines the surgical package as the operation, and also includes:

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

Medicare guidelines bundle additional services, including:

  • Preoperative visits after the decision is made to perform surgery, beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures
  • Intra-operative services that are normally a usual and necessary part of a surgical procedure
  • Complications following surgery—all additional medical and surgical services required of the surgeon during the post-op period due to complications not requiring additional trips to the operating room (OR)
  • Post-op visits (follow-up visits in the post-op period of the surgery related to recovery from the surgery)
  • Post-surgical pain management by the surgeon
  • Supplies, except those identified as exclusions
  • Miscellaneous services integral to the surgical procedure, such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, line, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous (IV) lines, nasogastric (NG) and rectal tube; and changes and removal of tracheostomy tubes

Payment for all of these services is considered part of the global payment and may not be billed separately. To bill separately for any of these services could lead to duplicate payment.

Define What Is NOT Included

Not everything is bundled into the surgical package. The following services are never bundled and are separately billable during the global period:

  • Care of pre-existing conditions
  • Care of new problems arising during the post-op period
  • Care of the underlying disease process when this is not cured by the surgical procedure
  • Services of other physicians, except where the surgeon and the other physician(s) agree on a transfer of care
  • Diagnostic tests and procedures, including diagnostic radiological procedures
  • Treatment for post-op complications that require a return trip to the OR
  • Procedures that are planned to be performed in stages
  • Immunosuppressive therapy for organ transplants

One of the most challenging issues related to separately billable services is the fourth bullet above: “Services of other physicians, except where the surgeon and the other physician(s) agree on a transfer of care.”

This exception is meant to clarify that medically necessary care outside the surgeon’s skill set is separately billable when performed by a physician in another specialty. For example, the surgeon is expected to take care of the patient’s post-op wound and manage healing. But, if the patient develops an infection and the surgeon needs assistance from an infectious disease (ID) specialist, the ID physician may bill separately for his or her services.

This is not a “blank check” to bill separately for services that are part of the surgical package when performed by other physicians. Medicare and other payers do not intend to pay twice for the same services. When the American Medical Association (AMA) Relative Value Update Committee (RUC) values surgical procedures, it includes the costs associated with the surgical package—including the history and physical (H&P) or clearance for surgery, typical inpatient follow-up care (which can include critical care level services for some procedures), and outpatient follow-up visits with removal of stitches and staples, dressing changes, and other appropriate post-op care. When these services, which are already paid as part of the surgical package payment, are performed by other physicians, there are a number of factors to consider when deciding how to bill.

Pre-op H&P

A pre-op H&P is included in the surgical package; however, if the patient has medical conditions that require separate clearance and management beyond the standard H&P, these services can be billed separately. These circumstances might occur if the patient develops a new problem, or experiences another significant status change in the days prior to surgery (e.g., A urologist schedules a patient for a transurethral resection of the prostate (TURP). Because the patient also has a heart condition, the urologist sends the patient to a cardiologist for preoperative clearance). To establish medical necessity for the visit, you’ll need to link the appropriate diagnosis or signs and symptoms to any E/M service reported.

If the surgeon routinely sends his or her otherwise healthy patients to primary care physicians for clearance, even when there is no medical necessity for that service, the primary care physicians are in a tough spot. The clearance is part of the surgical package and shouldn’t be paid twice. There is also no medical necessity for a separate E/M service unrelated to the surgery. This means that the primary care physicians cannot bill for services, or must send patients back to the surgeon for this care.

If the surgeon reduces his package payment, primary care physicians can bill for the standard pre-op care; although, CMS dictates the surgical package should not routinely be broken. Unless the patient cannot reasonably receive this service from the surgeon because of geographic distance or other factors, Medicare considers it abuse to cause unnecessary extra costs and risks in processing two claims (one for the surgeon and one for the primary care physician).

Inpatient Follow up

Highly complex postop management is typical for patients who have had heart surgery, brain surgery, transplants, and other procedures requiring close monitoring in the intensive care unit (ICU)—even when everything is normal—and the reimbursement for that level of post-op care is included in the package payment. This can be a problem in hospitals with “closed” ICUs staffed by certified intensivists. If the intensivists try to bill their services in the post-op period, when the monitoring is simply the appropriate critical care level monitoring required after the procedure, they will find that these services are included in the package reimbursement and are not separately billable.

Find Billing Solutions

If the surgeon hands off work for which he or she has already been paid as part of the surgical package, the physician who performs this work must be careful how he or she bills.

If the surgeon has reduced his or her package billing using modifier 54 Surgical care only, the other physician(s) involved in the patient’s care can bill for his or her services using modifiers 55 Postoperative management only and 56 Preoperative management only. If this happens routinely, it’s possible the practice will be questioned because it adds claims processing costs to the payer, and is unnecessary if there is no reason for splitting the package.

Some surgeons have found that having this care provided by someone else with whom they have developed special contracts is very beneficial to them and to the patient. The surgeon pays another physician separately for the pre-op work included in the package payment. This can be especially advantageous because the patients get good care; the surgeons are not stuck in the clinic when they’d rather be in the OR; and the primary care physician providing follow-up care gets reimbursed for his or her work. Surgeons choosing this option should be careful to prove the full surgical package was performed for the patient because this issue is under Office of Inspector General (OIG) and recovery audit contractor (RAC) scrutiny.

Surgeons may hire someone into the practice to handle these patient care services, which resolves the aforementioned problems. With appropriate documentation, these individuals may bill separately for those medically necessary services identified as separately billable, and may be motivated to do so because they do not have surgical reimbursement to offset the cost of their practice.

When looking for ways to resolve payment issues related to the surgical package, physicians and surgeons must consider OIG, Medicare administrative contractor (MAC), RAC, and zone program integrity contractor (ZPIC) issues, as well as Medicaid and commercial payer issues. Proper surgical package billing should be a priority in any surgical office, or any other practice that collaborates with surgeons for care related to surgical procedures.

Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS, CCS-P, is internal audit manager at Chan Healthcare. She is the long-time consulting editor for General Surgery Coding Alert, and has presented at five AAPC national meetings.

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