General Surgery Coding Alert

Medicare guidelines stipulate that evaluation and management services provided the day before or the day of a major surgery (i.e., a surgery with a 90-day global period) are included in the surgery's global package and are not separately reimbursable. If the preoperative exam prompted the decision for surgery, however, separate reimbursement is warranted and may be achieved if the visit is properly documented and modifier -57 (Decision for surgery) has been appended. 'Global'Services Versus Decision for Surgery According to Medicare's global surgery rules, payment for surgical procedures includes the surgery itself (the intraoperative"" portion of the service)" as well as all postoperative care that does not require a return trip to the operating room for a duration of zero 10 or 90 days depending on the procedure. In addition the global surgical package generally includes all preoperative visits with the patient after the decision for surgery has been made beginning with the day before surgery for major procedures and the day of surgery for minor procedures i.e. procedures with zero- or 10-day global periods. For example a patient previously scheduled to undergo laparoscopic cholecystectomy (47562 ... cholecystectomy) visits the surgeon the day before surgery for a final exam and to discuss last-minute concerns. In this case the E/M visit is included in the global surgical package for 47562 and you may not report it separately. On occasion however the decision for surgery which is typically made days or weeks before may be made the day prior to or even the day of the operation. For instance the surgeon is asked to evaluate a patient for acute right-upper quadrant pain and tenderness and upon full evaluation decides the gallbladder must be removed and schedules an immediate laparoscopic cholecystectomy. In such cases Medicare will allow separate reimbursement for the preoperative E/M service if certain conditions are met. The Medicare Carriers Manual (MCM) section 15501.1 instructs carriers to "Pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service was for the decision to perform the procedure." The modifier must be appended to the E/M service code not the surgical procedure code. Modifier -57 need not be appended to E/M services that would normally fall outside the global surgical period e.g. an E/M visit five days before surgery. Therefore in the above example of emergency lap chole the surgeon may report both the surgical procedure and the examination that led to the decision to perform the surgery as long as modifier -57 is appended to the appropriate E/M service code e.g. 99243 (Office consultation for a new or established patient [...]