(Medicare Claims Processing Manual)

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  See 40.2.A.8, 40.2.A.9 , and 40.4.A for instances where prepayment review is required for modifier  -25.  In addition, prepayment review is necessary for CPT codes 90935, 90937, 90945, and 90947 when a visit and modifier - 25 are billed with these services.   Exclude the following codes from the prepayment edits required in 40.3.B.  92002  92004  99201  99202  99203  99204  99205  99281  99282  99283  99284  99285  99321  99322  99323  99341  99342  99343  99344  99345       40.4 - Adjudication of Claims for Global Surgeries  (Rev . 11287; Issued:03-02- 22; Effective:01 -01-22; Implementation: 02 -22-22)   A.  Fragmented Billing of Services Included in the Global Package   Since the Medicare fee schedule amount for surgical procedures includes all services that are part of the global surgery package, A/B MACs (B) do not pay more than that amount when a bill is fragmented.  When total charges for fragmented services exceed the global fee, process the claim as a fee schedule reduction (except where stated policies, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care, result in payment that is higher than the global surgery allowed amount).  A/B MACs (B) do not attribute such reductions to medical review savings except where the usual medical review process results in recoding of a service, and the recoded service is included in the global surgery package.  The maximum a nonparticipating physician may bill a beneficiary on an unassigned claim for services included in the global surgery package is the limiting charge for the surgical procedure.  In addition, the limitation of liability provision (1879 of the Act) does not apply to these determinations since they are fee schedule reductions, not denials based upon medical necessity or custodial care.   Claims for surgeries billed with a  -22 or -52 modifier, are priced by individual consideration if the statement and documentation required by 40.2.A.10 are included.  If the statement and documentation are not submitted with the claim, pricing  for - 22 is it the fee schedule rate for the same surgery submitted without the -22 modifier.  Pricing for -52 is not done without the required documentation.  Separate payment is allowed for visits and procedures billed with modifier  -78, - 79,  -24, -25, -57, or -58.  Modifier -24 must be accompanied by sufficient documentation that the visit is unrelated to the surgery.    Critical care services furnished during the global period must be unrelated to the procedure. Separate payment is allowed for unrelated visits when the -FT modifier ((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.)) is appended.  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.  A/B MACs (B) do not allow separate payment for evaluation and management services furnished on the same day or during the postoperative period of a surgery if the services are billed without modifier  -24, -25, -57 or -FT. These services should be denied.  A/B MACs (B) do not allow separate payment for visits during the postoperative period that are billed with the modifier  -24 or -FT but without sufficient documentation.  These services should also be denied.  Modifier -24 or - FT is intended  for use with services that are absolutely unrelated to the surgery.  It is not to be used for the medical management of a patient by the surgeon following surgery.  Recognize modifier -24 only for care following discharge unless:   The care is for immunotherapy management furnished by the transplant surgeon;    The documentation demonstrates that the visit occurred during a subsequent hospitalization and the diagnosis supports the fact that it is unrelated to the original surgery.  A/B MACs (B) do not allow separate payment for an additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior procedure and if billed without modifier  -58,  -78, or  -79.  These services should be de nied.  Codes with the global surgery indicator of XXX in the MFSDB can be paid separately without a modifier.  B.  Claims From Physicians Who Furnish Less Than the Global Package (Split Global Care)   For surgeries performed January 1, 1992, and later, that are billed with either modifier  -54 or -55, A/B MACs (B) pay the appropriate percentage of the fee schedule payment.  Fields 17-19 of the MFSDB list the appropriate percentages for pre -, intra -, and postoperative care of the total RVUs for major surgical procedures and for minor surgeries with a postoperative period of 10 days.  The intra -operative percentage includes postoperative hospital visits.   Procedures with a 000 entry in Field 16 have an entry of 0.0000 in Fields 17- 19.  Split global care does not apply to these procedures.   A/B MACs (B) multiply the fee schedule amount (Field 34 or Field 35 of the MFSDB) by this percentage and round to the nearest cent.  Assume that a physician who bills with a  -54 modifier has provided both preoperative, intra -operative and postoperative hospital  services.  Pay this physician the combined preoperative and intra -operative portions of the fee schedule payment amount.  Where more than one physician bills for the postoperative care, A/B MACs (B) apportion the postoperative percentage according to the number of days each physician was responsible for the patients care by dividing the postoperative allowed amount by the number of post -op days and that amount is multiplied by the number of days each physician saw the patient.   EXAMPLE   Dr. Jones bills for procedure 42145- 54 performed on March 1 and states that he cared for the patient through April 29.  Dr.  Smith bills for procedure 42145 -55 and states that she assumed care of the patient on April 30.  The percentage of the total fe e amount for the postoperative care for this procedure is determined to be 17 percent and the length of the global period is 90 days.  Since Dr. Jones provided postoperative care for the first 60 days, he will receive 66 2/3 percent of the total fee of 17 percent since 60/90 = .6666.  Dr. Smiths 30 days of service entitle her to 30/90 or .3333 of the fee.   6666 x .17 = .11333 or 11.3%; and   3338 x .17 = .057 or 5.7%.  Thus, Dr. Jones will be paid at a rate of 11.3 percent (66.7 percent of 17 percent).  Dr.  Smith will be paid at a rate of 5.7 percent (33.3 percent of 17 percent).   C.  Payment for Return Trips to the Operating Room for Treatment of Complications   When a CPT code billed with modifier  -78 describes the services involving a return trip to the operating room to deal with complications, A/B MACs (B) pay the value of the intra -operative services of the code that describes the treatment of the complicat ions.  Refer to Field 18 of the MFSDB to determine the percentage of the global package for the intra -operative services.  The fee schedule amount (Field 34 or 35 of the MFSDB) is multiplied by this percentage and rounded to the nearest cent.