(Medicare Claims Processing Manual)

The physician may need to indicate that the performance of a procedure or service during the postoperative period was:   a. Planned prospectively or at the time of the original procedure;  b. More extensive than the original procedure; or  c. For therapy following a diagnostic surgical procedure.   These circumstances may be reported by adding modifier  -58 to the staged procedure.  A new postoperative period begins when the next procedure in the series is billed.  7. Unrelated Procedures or Visits During the Postoperative Period   Modifiers were established to simplify billing for visits and other procedures which are furnished during the postoperative period of a surgical procedure, but which are not included in the payment for the surgical procedure.   Modifier  -79:  Reports an unrelated procedure by the same physician during a postoperative period.  The physician may need to indicate that the performance of a procedure or service during a postoperative period was unrelated to the original procedure.   A new postoperative period begins when the unrelated procedure is billed.   Modifier  -24: Reports an unrelated evaluation and management service by same physician during a postoperative period.  The physician may need to indicate that an evaluation and management service was performed during the postoperative period of an unrelated procedure.  This circumstance is reported by adding the modifier  -24 to the appropriate level of evaluation and management service.   Services submitted with the  -24 modifier must be sufficiently documented to establish that the visit was unrelated to the surgery.  A diagnosis code that clearly indicates that the reason for the encounter was unrelated to the surgery is acceptable docum entation.  A physician who is responsible for postoperative care and has reported and been paid using modifier  -55 also uses modifier  -24 to report any unrelated visits.   For critical care visits that are unrelated to the surgical procedure and performed postoperatively, report modifier FT as discussed in section 30.6.12.7 of this chapter.   8. Significant Evaluation and Management on the Day of a Procedure   Modifier  -25 is used to facilitate billing of evaluation and management services on the day of a procedure for which separate payment may be made.   It is used to report a significant, separately identifiable evaluation and management service by same physician on the day of a procedure.  The physician may need to indicate that on the day a procedure or service that is identified with a CPT code was performed, the patients condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed.  This circumstance may be report ed by adding the modifier  -25 to the appropriate level of evaluation and management service.   Claims containing evaluation and management codes with modifier  -25 are not subject to prepayment review except in the following situations:    Effective January 1, 1995, all evaluation and management services provided on the same day as inpatient dialysis are denied without review with the exception of CPT Codes 99221- 9223, 99251- 99255, and 99238.  These codes may be billed with modifier -25 an d reviewed for possible allowance if the evaluation and management service is unrelated to the treatment of ESRD and was not, and could not, have been provided during the dialysis treatment;   When preoperative critical care codes are being billed within a global surgical period; and   When A/B MACs (B) have conducted a specific medical review process and determined, after reviewing the data, that an individual or group has high statistics in terms of the use of modifier  -25, have done a case- by-case review of the records to verify tha t the use of modifier  -25 was inappropriate, and have educated the individual or group as to the proper use of this modifier.   For critical care visits that are unrelated to the surgical procedure but performed on the same day, report modifier - FT as discussed in section 30.6.12.7 of this chapter for further discussion of critical care visits unrelated to the procedure with a global surgical period.   9. Critical Care   Critical care services provided during a global surgical period must be unrelated to a surgical procedure and appended with the modifier - FT.  For further information see section 30.6.12.7 of this chapter for further discussion of critical care visits unrelated to the procedure with a global surgical period.   10. Unusual Circumstances   Surgeries for which services performed are significantly greater than usually required may be billed with the  -22 modifier added to the CPT code for the procedure.  Surgeries for which services performed are significantly less than usually required may be billed with the - 52 modifier.  The biller must provide:    A concise statement about how the service differs from the usual; and    An operative report with the claim.   Modifier  -22 should only be reported with procedure codes that have a global period of 0, 10, or 90 days.  There is no such restriction on the use of modifier  -52.  B. Date(s) of Service   Physicians, who bill for the entire global surgical package or for only a portion of the care, must enter the date on which the surgical procedure was performed in the From/To date of service field.  This will enable A/B MACs (B) to relate all appropriate billings to the correct surgery.  Physicians who share postoperative management with another physician must submit additional information showing when they assumed and relinquished responsibility for the postoperative care.  If the physician who performe d the surgery relinquishes care at the time of discharge, he or she need only show the date of surgery when billing with modifier  -54.  However, if the surgeon also cares for the patient for some period following discharge, the surgeon must show the date of surgery and the date on which postoperative care was relinquished to another physician.  The physician providing the remaining postope rative care must show the date care was assumed.  This information should be shown in Item 19 on the paper Form CMS -1500.  See the related implementation guide for where to show this information on the ASC X12 837 professional claim transaction format.   C. Care Provided in Different Payment Localities   If portions of the global period are provided in different payment localities, the services should be billed to the A/B MAC (B) servicing each applicable payment locality.  For example, if the surgery is performed in one state and the postoperative care is  provided in another state, the surgery is billed with modifier  -54 to the A/B MAC (B) servicing the payment locality where the surgery was performed and the postoperative care is billed with modifier  -55 to the A/B MAC (B) servicing the payment locali ty where the postoperative care was performed.  This is true whether the services were performed by the same physician/group or different physicians/groups.  D. Health Professional Shortage Area (HPSA) Payments for Services Which Are Subject to the Global Surgery Rules   HPSA bonus payments may be made for global surgeries when the services are provided in HPSAs.  The following are guidelines for the appropriate billing procedures:    If the entire global package is provided in a HPSA, physicians should bill for the appropriate global surgical code with the applicable HPSA modifier.   If only a portion of the global package is provided in a HPSA, the physician should bill using a HPSA modifier for the portion which is provided in the HPSA.  EXAMPLE   The surgical portion of the global service is provided in a non- HPSA and the postoperative portion is provided in a HPSA.  The surgical portion should be billed with the  -54 modifier and no HPSA modifier.  The postoperative portion should be billed with the  -55 modifier and the appropriate HPSA modifier.  The 10 percent bonus will be paid on the appropriate postoperative portion only.  If a claim is submitted with a global surgical code and a HPSA modifier, the A/B MAC (B) assumes that the entire global service was provided in a HPSA in the absence of evidence otherwise.   NOTE:  The sum of the payments made for the surgical and postoperative services provided in different localities will not equal the global amount in either of the localities because of geographic adjustments made through the Geographic Practice Cost Indices.  40.3 - Claims Review for Global Surgeries  (Rev. 11287; Issued:03- 02-22; Effective:01 -01-22; Implementation: 02 -22-22)  A. Relationship to Correct Coding Initiative (CCI)   The CCI policy and computer edits allow A/B MACs (B) to detect instances of fragmented billing for certain intra -operative services and other services furnished on the same day as the surgery that are considered to be components of the surgical procedure a nd, therefore, included in the global surgical fee.  When both correct coding and global surgery edits apply to the same claim, A/B MACs (B) first apply the correct coding edits, then, apply the global surgery edits to the correctly coded services.  B. Prepayment Edits to Detect Separate Billing of Services Included in the Global Package   In addition to the correct coding edits, A/B MACs (B) must be capable of detecting certain other services included in the payment for a major or minor surgery or for an endoscopy.  On a prepayment basis, A/B MACs (B) identify the services that meet the following conditions:    Preoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure; or    Same day or postoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure or endoscopy;   and -   Services that were furnished within the prescribed global period of the surgical procedure;    Services that are billed without modifier  -78,  -79,  -24, 25, or  -57 or are billed with modifier  -24 but without the required documentation; and    Services that are billed with the same provider or group number as the surgical procedure or endoscopy.  Also, edit for any visits billed separately during the postoperative period without modifier  -24 by a physician who billed for the postoperative care  only with modifier  -55.  A/B MACs (B) use the following evaluation and management codes in establishing edits for visits included in the global package.  CPT codes 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99271, 99272, 99273, 99274, and 99275 have been transferred from the excluded category and are now included in the global surgery edits.   Evaluation and Management Codes for A/B MAC (B) Edits   92012  92014  99211  99212  99213  99214  99215  99217  99218  99219  99220  99221  99222  99223  99231  99232  99233  99234  99235  99236  99238  99239  99241  99242  99243  99244  99245  99251  99252  99253  99254  99255  99261  99262  99263  99271  99272  99273  99274  99275  99291  99292  99301  99302  99303  99311  99312  99313  99315  99316  99331  99332  99333  99347  99348  99349  99350     99374  99375  99377  99378     NOTE:   In order for the services of CPT codes 99291 or 99292 to be paid during the preoperative or postoperative period, the critical care service must be unrelated to the procedure. In these situations, the physician must append the modifier -FT ((unrelated evaluation and management (E/M) visit on the same day as another E/M visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable). (Report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional  E/M visits furnished on the same day are unrelated.))  See section 30.6.12.7 of this chapter for further discussion of critical care visits unrelated to the procedure with a global surgical period.   If a surgeon is admitting a patient to a nursing facility for a condition not related to the global surgical procedure, the physician should bill for the nursing facility admission and care with a -24 modifier and appropriate documentation.  If a surgeon is admitting a patient to a nursing facility and the patients admission to that facility relates to the global surgical procedure, the nursing facility admission and any services related to the global surgical procedure are included in the global surgery fee.   C. Exclusions from Prepayment Edits   A/B MACs (B) exclude the following services from the prepayment audit process and allow separate payment if all usual requirements are met:   Services listed in 40.1.B ; and  Services billed with the modifier  -25,   -57,   -58,   -78, or  -79.  Exceptions