Help with procedure during global

amartinez1

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Patient was seen for post op check up in the office and the physician noticed an abscess on the wound she was sent to the hospital for an I&D on the same day.its my understanding that only the I&D could be billed and not the E&M for post op complication. Need help if I am wrong. While the doctor was doing procedure he said the previous rotator cuff repair did not work do to the infection. If the physician goes back in after infection is cured can I rebill for second repair? Also I am a little confused as to which cot code to use for the I&D. He did a primary closure with a drain placement.would it be the 23031 or the 10180? Thanks for anyone that will help.
 

btadlock1

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Patient was seen for post op check up in the office and the physician noticed an abscess on the wound she was sent to the hospital for an I&D on the same day.its my understanding that only the I&D could be billed and not the E&M for post op complication. Need help if I am wrong. While the doctor was doing procedure he said the previous rotator cuff repair did not work do to the infection. If the physician goes back in after infection is cured can I rebill for second repair? Also I am a little confused as to which cot code to use for the I&D. He did a primary closure with a drain placement.would it be the 23031 or the 10180? Thanks for anyone that will help.
1. Post-op complications are not considered part of the surgical global package. You can bill for evaluating/treating them.
2. You can bill for the second repair if another repair is done; you'd want to use modifier 77 to indicate that it's a repeat of the same procedure by another physician.
3. 23031 is probably the more appropriate code for this situation, but it's hard to say without seeing the actual note. 10180 is only for the integumentary system, but since the area being drained is in the shoulder bursa, then you'd need to reflect that by choosing a code from the musculoskeletal system.

Hope that helps! ;)
 

btadlock1

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you can use modifier 57 on E/M code.
You would use a 25 modifier if it was on the same day as the procedure. 57 would be for a visit on a date prior to the procedure, when the decision for surgery was made. And yes, amartinez1, you can do that.;)
 

armen

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You would use a 25 modifier if it was on the same day as the procedure. 57 would be for a visit on a date prior to the procedure, when the decision for surgery was made. And yes, amartinez1, you can do that.;)
I did not pay attention that CPT 23031 has only 10 days global. If it would be 90 days global I would still bill -57 even if E/M was the same day of surgery.

Pub 100-04 Medicare Claims Processing Transmittal 954:
C. CPT Modifier “-57” - Decision for Surgery Made Within Global Surgical Period
Carriers pay for an evaluation and management 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 resulted in the decision to perform the procedure. Carriers may no pay for an evaluation and management service billed with the CPT modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period.
 

btadlock1

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I did not pay attention that CPT 23031 has only 10 days global. If it would be 90 days global I would still bill -57 even if E/M was the same day of surgery.

Pub 100-04 Medicare Claims Processing Transmittal 954:
C. CPT Modifier “-57” - Decision for Surgery Made Within Global Surgical Period
Carriers pay for an evaluation and management 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 resulted in the decision to perform the procedure. Carriers may no pay for an evaluation and management service billed with the CPT modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period.
I wouldn't in this case, because it's not a major surgery.
http://www.medicarenhic.com/providers/articles/BillingTipsGlobalSurgery.pdf

"The following information is a recap of the global policy and the appropriate modifiers to use to identify the exceptions. A “global surgical fee” includes all necessary services performed by the physician before, during, and after a surgical procedure. Medicare payment for a given surgical procedure includes applicable pre-operative and intra-operative services, complications, and post-operative care. Procedure codes with ninety (90) follow-up days are considered major surgeries. Procedure codes with zero (0) or ten (10) follow-up days are considered minor surgeries. The components which are included in the global surgical fee are:
1. Pre-operative visits-These visits are defined as the visits one (1) day before or the same day as a surgical procedure. Preoperative visits are not paid separately unless the provider indicates that the service was a significant, separately identifiable service (modifier 25) or the service was a decision for major surgery (modifier 57)."
 

armen

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I wouldn't in this case, because it's not a major surgery.
http://www.medicarenhic.com/providers/articles/BillingTipsGlobalSurgery.pdf

"The following information is a recap of the global policy and the appropriate modifiers to use to identify the exceptions. A “global surgical fee” includes all necessary services performed by the physician before, during, and after a surgical procedure. Medicare payment for a given surgical procedure includes applicable pre-operative and intra-operative services, complications, and post-operative care. Procedure codes with ninety (90) follow-up days are considered major surgeries. Procedure codes with zero (0) or ten (10) follow-up days are considered minor surgeries. The components which are included in the global surgical fee are:
1. Pre-operative visits-These visits are defined as the visits one (1) day before or the same day as a surgical procedure. Preoperative visits are not paid separately unless the provider indicates that the service was a significant, separately identifiable service (modifier 25) or the service was a decision for major surgery (modifier 57)."
lol that is what I said:) "If it would be 90 days global I would still bill -57 even if E/M was the same day of surgery"
I agreed with you on this case, 57 would not be appropriate since the code has only 10 days global and as you said its not a "major procedure"
However, I dont agree that 25 is for "same day" surgery and 57 is for ''the day befor":)
 

btadlock1

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I misunderstood your post when you said you'd still use 57 the day of the procedure - I thought you were referring to this procedure in particular, as opposed to just when to use it, in general. I actually didn't know the 57 was primarily meant for use on major surgeries only, and I can't remember whether I've ever seen it used on the same day or not. (The majority of our providers are family practice/IM, so most of them don't do a whole lot of surgeries. Even if they did, I'm not a coder/biller, so I'd probably never know about it if it didn't deny...)

I got the 'day before' thing, from the CPT Surgical Package definitions, where it says: " Subsequent to the decision for surgery, on related E/M encounter on the day immediately prior to or on the date of procedure (including H&P)".

My thinking was (this may be kind of hard to follow...my logic's a little spacey), the incuded pre-op exam happens after the decision for surgery, so if the pre-op exam is the day before the surgery, then the 'decision for surgery' visit must also be at least one day before the surgery. I've always used modifier 25 if it all happens at once, because in modifier 25's definition, it says "The E/M service may be prompted by the symptom or condition for which the procedure/service was provided. As such, different diagnoses aren't required for reporting of E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service."

The note right after that is kind of confusing (in the way that it's worded - I understand what it means), where it says, "Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57." It sounds kind of contradictory, especially when you consider that nearly all procedures are located in the "Surgery" section of the CPT book, and none of them have their global days listed. As far as I know, the CPT book doesn't define the difference between a "surgery" and a surgical "procedure". It would be nice if they'd clarify it in the book, since their connotations are hard to interpret...Just my two cents! :rolleyes:
 

armen

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I misunderstood your post when you said you'd still use 57 the day of the procedure - I thought you were referring to this procedure in particular, as opposed to just when to use it, in general. I actually didn't know the 57 was primarily meant for use on major surgeries only, and I can't remember whether I've ever seen it used on the same day or not. (The majority of our providers are family practice/IM, so most of them don't do a whole lot of surgeries. Even if they did, I'm not a coder/biller, so I'd probably never know about it if it didn't deny...)

I got the 'day before' thing, from the CPT Surgical Package definitions, where it says: " Subsequent to the decision for surgery, on related E/M encounter on the day immediately prior to or on the date of procedure (including H&P)".

My thinking was (this may be kind of hard to follow...my logic's a little spacey), the incuded pre-op exam happens after the decision for surgery, so if the pre-op exam is the day before the surgery, then the 'decision for surgery' visit must also be at least one day before the surgery. I've always used modifier 25 if it all happens at once, because in modifier 25's definition, it says "The E/M service may be prompted by the symptom or condition for which the procedure/service was provided. As such, different diagnoses aren't required for reporting of E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service."

The note right after that is kind of confusing (in the way that it's worded - I understand what it means), where it says, "Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57." It sounds kind of contradictory, especially when you consider that nearly all procedures are located in the "Surgery" section of the CPT book, and none of them have their global days listed. As far as I know, the CPT book doesn't define the difference between a "surgery" and a surgical "procedure". It would be nice if they'd clarify it in the book, since their connotations are hard to interpret...Just my two cents! :rolleyes:
Yeah, its a real problem that there is no clear definition of surgical procedures in CPT, and a lot of payors use this to reduce the payment based on multiple surgery rule. Imagine having a 50% reduction on a cast application code just because it is in a surgery section of CPT, I dont think anyone consideres cast application as surgery:)

Uniform Discharge Data Set defines surgery as: incision, excision, amputation, introduction, endoscopy, repair, destruction, suture and manipulation. However, neither this nor any other definition of surgery has been used to place codes in any particular section of the CPT code set. Its just created to be convenient to find the codes:)
 

amartinez1

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Yeah, its a real problem that there is no clear definition of surgical procedures in CPT, and a lot of payors use this to reduce the payment based on multiple surgery rule. Imagine having a 50% reduction on a cast application code just because it is in a surgery section of CPT, I dont think anyone consideres cast application as surgery:)

Uniform Discharge Data Set defines surgery as: incision, excision, amputation, introduction, endoscopy, repair, destruction, suture and manipulation. However, neither this nor any other definition of surgery has been used to place codes in any particular section of the CPT code set. Its just created to be convenient to find the codes:)
One more question regarding post operative infection complications. If patient presented with an infection at the surgical site and the physician did not perform surgery but did send patient home with a prescription for antibiotics can an E/M still be billed as a complication during the global surgery with modifier 24
 

RebeccaWoodward*

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Just FYI-

Medicare includes complications as part of the surgical package. Unless it's an unrelated problem, the E/M is not billable.

A. Components of a Global Surgical Package

"Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room;"

Page 91

http://www.cms.gov/manuals/downloads/clm104c12.pdf
 

nyyankees

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Just FYI-

Medicare includes complications as part of the surgical package. Unless it's an unrelated problem, the E/M is not billable.

A. Components of a Global Surgical Package

"Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room;"

Page 91

http://www.cms.gov/manuals/downloads/clm104c12.pdf
I agree....
 
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