General Surgery Coding Alert

You could charge separate E/M, in many cases.

A big surprise hit the presses in the July 11 proposed rule for the Medicare Physician Fee Schedule (PFS). CMS proposes severely cutting global periods for surgical procedures — a move that could impact pay for many procedures that your general surgeon performs. 

Although the proposal is not firm and would not go into effect until 2017, your practice should learn the facts now so that you can look out for your future bottom line. 

Eliminate 10- and 90-Day Global Periods

You might be surprised to learn what CMS is suggesting. “We are proposing to transform all 10- and 90-day global codes to 0-day global codes beginning in CY 2017,” CMS says in a fact sheet about the fee schedule proposal.

Why? “The OIG has identified a number of surgical procedures that include more visits in the global period than are being furnished.” Because CMS seems to believe that Medicare is wasting cash by paying doctors for global periods that include visits the doctors don’t actually perform, CMS is proposing to include “all services provided on the day of surgery, and to pay separately for visits and services actually furnished after the day of the procedure …” CMS says in its fact sheet.

Impact: This would mean that you could bill any postoperative services on an a la carte basis instead of bundling all related post-operative care into the surgical charge. 

“Surgeons may welcome this change, but whether it bodes well or ill for general surgery practices really depends on how CMS decides to value the surgical codes once the agency removes the global periods from the value units,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

Caution: If CMS goes through with this proposal, the agency will be watching patterns of billing post-op E/M services. “We [want to] ensure that allowing separate payment of E/M visits during post-operative periods does not incentivize otherwise unnecessary office visits during post-operative periods. If we adopt this proposal, we intend to monitor any changes in the utilization of E/M visits following its implementation.”

Learn more: You can read the CMS proposal and find out how to comment at www.federalregister.gov/articles/2014/07/11/2014-15948/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory.

Review Current Practices

Currently, your general surgeon performs surgical procedures that fall primarily into one of three categories: 0 global days, 10 global days, or 90 global days.

What this means: The global surgical package “includes all necessary services normally furnished by a surgeon before, during, and after a procedure,” according to CMS. That includes pre-op, intra-op, and post-op services by your surgeon or any member of your surgical group.

Here are the current groupings:

0-day: Zero-day global surgeries include to procedures like endoscopies and other minor surgeries, such 19100 (Biopsy of breast; percutaneous, needle core, not using imaging guidance [separate procedure]). For these procedures, there is no pre-operative or post-operative period, but you can’t separately bill an E/M service that is related to the surgery on the day of the procedure.

10-day: A 10-day global period consists of 11 actual days, including the day of the surgery and 10 days following the day of surgery. No pre-operative period is included. Many minor surgical procedures carry a 10-day global period, such as 19101 (Biopsy of breast; open, incisional) and 46221 (Hemorrhoidectomy, internal, by rubber band ligation[s]).

90-day: A procedure with a global period of 90 days consists of 92 days — one day before the procedure, the day of surgery, and the 90 days of post-operative care immediately following the surgery. You’ll find that major surgical procedures carry a 90-day global period, such as 49585 (Repair umbilical hernia, age 5 years or older; reducible) and 19307 (Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle). 

During these global periods, you shouldn’t separately bill E/M services that are part of the normal pre-op, surgical, or post-op care. That includes any E/M procedure provided during the post-operative period that is related to the recovery from the surgery, including pain management.

For example: Your surgeon removes a malignant lesion from a patient’s face with a procedure such as 11644 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm). Five days following surgery, the patient notices irritation and redness around the wound site and requires an evaluation to determine if the site is infected. Your surgeon prescribes antibiotics for a minor infection.

“This visit would be considered related to the actual procedure performed, and would fall under the guidelines of post-op care,” explains Sharon Morehouse, MPA, IA, owner of Beyond Basics Medical Billing Service, LLC of Honeoye Falls, N.Y. “An additional E/M code could not be billed for these services.”