evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
40 - Surgeons and Global Surgery  (Rev. 1, 10- 01-03) B3-4820  A national definition of a global surgical package has been established to ensure that payment is made consistently for the same services across all A/B MAC (B) jurisdictions, thus preventing Medicare payments for services that are more or less comprehensi ve than intended.  The national global surgery policy became effective for surgeries performed on and after January 1, 1992.  The instructions that follow describe the components of a global surgical package and payment rules for minor surgeries, endoscopies and global surgical packages that are split between two or more physicians.  In addition, billing, mandatory edits, claims review, adjudication, and postpayment instructions are included.  In addition to the global policy, uniform payment policies and claims processing requirements have been established for other surgical issues, including bilateral and multiple surgeries, co-surgeons, and team surgeries. 40.1 - Definition of a Global Surgical Package  (Rev . 11287; Issued:03- 02-22; Effective:01 -01-22; Implementation: 02 -22-22)  B3-4821, B3- 15900.2  Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods that apply to each surgical procedure.  The payment rules for surgical procedures apply to codes with entries of 000, 010, 090, and, sometimes, YYY.  Codes with 090 in Field 16 are major surgeries.  Codes with 000 or 010 are either minor surgical procedures or endoscopies. Codes with YYY are A/B MAC (B) -priced codes, for which A/B MACs (B) determine the global period (the global period for these codes will be 0, 10, or 90 days).  Note that not all A/B MAC (B) -priced codes have a YYY global surgical indicator; sometimes t he global period is specified.  While codes with ZZZ are surgical codes, they are add -on codes that are always billed with another service.  There is no postoperative work included in the fee schedule payment for the ZZZ codes.  Payment is made for both the primary and the add- on cod es, and the global period assigned is applied to the primary code.
(Medicare Claims Processing Manual)
A. Components of a Global Surgical Package  B3-15011, B3- 4820- 4831  A/B MACs (B) apply the national definition of a global surgical package to all procedures with the appropriate entry in Field 16 of the MFSDB.   The Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery.  The services included in the global surgical package may be furnished in any set ting, e.g., in hospitals, ASCs, physicians offices.  Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon.  However, critical care services (CPT codes 99291 and 99292) are payable separately in some situa tions. (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.)   Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;   Intra -operative Services -  Intra -operative services that are normally a usual and necessary part of a surgical procedure;   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;   Postoperative Visits -  Follow -up visits during the postoperative period of the surgery that are related to recovery from the surgery;   Postsurgical Pain Management -  By the surgeon;   Supplies -  Except for those identified as exclusions; and  Miscellaneous Services -  Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
(Medicare Claims Processing Manual)
B. Services Not Included in the Global Surgical Package  A/B MACs (B) do not include the services listed below in the payment amount for a procedure with the appropriate indicator in Field 16 of the MFSDB.  These services may be paid for separately.   The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.  Please note that this policy only applies to major surgical procedures.  The initial evaluation is always included in the allowance for a minor surgica l procedure;   Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care.  This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;   Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;   Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;   Diagnostic tests and procedures, including diagnostic radiological procedures;   Clearly distinct surgical procedures during the postoperative period which are not re -operations or treatment for complications.  (A new postoperative period begins with the subsequent procedure.)  This includes procedures done in two or more parts for whi ch the decision to stage the procedure is made prospectively or at the time of the first procedure.  Examples of this are procedures to diagnose and treat epilepsy (codes 61533, 61534- 61536, 61539, 61541, and 61543) which may be performed in succession within 90 days of each other;   Treatment for postoperative complications which requires a return trip to the operating room (OR).  An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures.  The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite.  It does not include a patients room, a minor treatment room, a recovery room, or an intensive care unit (unless the patients condition was so critical there would be insufficient time for transportation to an OR);   If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;   For certain services performed in a physicians office, separate payment can no longer be made for a surgical tray (code
(Medicare Claims Processing Manual)
 If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;   For certain services performed in a physicians office, separate payment can no longer be made for a surgical tray (code A4550).  This code is now a Status B and is no longer a separately payable service on or after January 1, 2002.  However, splints and c asting supplies are payable separately under the reasonable charge payment methodology;   Immunosuppressive therapy for organ transplants; and  Critical care services (CPT codes 99291 and 99292) unrelated to the surgery, for example, where a seriously injured or burned patient is critically ill and requires constant attendance of the physician. 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.
(Medicare Claims Processing Manual)
C. Minor Surgeries and Endoscopies   Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.  For example, a visit on the same day could be properly bil led in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma.  Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.  A postoperative period of 10 days applies to some minor surgeries.  The postoperative period for these procedures is indicated in Field 16 of the MFSDB.  If the Field 16 entry is 010, A/B MACs (B) do not allow separate payment for postoperative visits or s ervices within 10 days of the surgery that are related to recovery from the procedure.  If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the 10- day period, the major surgery is payable separately.  Services by other physicians are not included in the global fee for a minor procedures except as otherwise excluded.  If the Field 16 entry is 000, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery.  Separat e payment is made in this instance.  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.   D. Physicians Furnishing Less Than the Full Global Package  B3-4820 -4831   There are occasions when more than one physician provides services included in the global surgical package.  It may be the case that the physician who performs the surgical procedure does not furnish the follow -up care.  Payment for the postoperative, post -discharge care is split between two or more physicians where the physicians agree on the transfer of care.
(Medicare Claims Processing Manual)
When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services (except where stated po licies, 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 allowed amount).   Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.   E. Determining the Duration of a Global Period   To determine the global period for major surgeries, A/B MACs (B) count 1 day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery.   EXAMPLE:  Date of surgery -  January 5  Preoperative period -  January 4  Last day of postoperative period -  April 5  To determine the global period for minor procedures, A/B MACs (B) count the day of surgery and the appropriate number of days immediately following the date of surgery.   EXAMPLE:  Procedure with 10 follow -up days:  Date of surgery -  January 5  Last day of postoperative period -  January 15   40.2 - Billing Requirements for Global Surgeries  (Rev.  11287; Issued:03- 02-22; Effective:01 -01-22; Implementation: 02 -22-22)  To ensure the proper identification of services that are, or are not, included in the global package, the following procedures apply.   A. Procedure Codes and Modifiers   Use of the modifiers in this section apply to both major procedures with a 90- day postoperative period and minor procedures with a 10- day postoperative period (and/or a zero day postoperative period in the case of modifiers  -22 and  -25).   1. Physicians Who Furnish the Entire Global Surgical Package   Physicians who perform the surgery and furnish all of the usual pre -and postoperative work bill for the global package by entering the appropriate CPT code for the surgical procedure only.  Billing is not allowed for visits or other services that are inclu ded in the global package.   2. Physicians in Group Practice
(Medicare Claims Processing Manual)
2. Physicians in Group Practice   When different physicians in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group.  The physician who performs the surgery is shown as the performing physician.  (For dates of service prior to January 1, 1994, however, where a new physician furnishes the entire postoperative care, the group billed for the surgical care and the postoperative c are as separate line items with the appropriate modifiers.)   3. Physicians Who Furnish Part of a Global Surgical Package   Where physicians agree on the transfer of care during the global period, the following modifiers are used:   -54 for surgical care only; or   -55 for postoperative management only.   Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.   Providers need not specify on the claim that care has been transferred.  However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim.  This should be indicated in the remarks field/free text segment on the claim form/format.  Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiarys medical record.   Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service.  Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he/she assumes care of the patient.   EXCEPTIONS:    Where a transfer of care does not occur, occasional post -discharge services of a physician other than the surgeon are reported by the appropriate evaluation and management code.  No modifiers are necessary on the claim.    If the transfer of care occurs immediately after surgery, the physician other than the surgeon who provides the in- hospital postoperative care bills using subsequent hospital care codes for the inpatient hospital care and the surgical code with the - 55 m odifier for the post -discharge care.  The surgeon bills the surgery code with the  -54 modifier.
(Medicare Claims Processing Manual)
 Physicians who provide follow -up services for minor procedures performed in emergency departments bill the appropriate level of office visit code.  The physician who performs the emergency room service bills for the surgical procedure without a modifier.    If the services of a physician other than the surgeon are required during a postoperative period for an underlying condition or medical complication, the other physician reports the appropriate evaluation and management code.  No modifiers are necessary on the claim.  An example is a cardiologist who manages underlying cardiovascular conditions of a patient.   4. Evaluation and Management Service Resulting in the Initial Decision to Perform Surgery   Evaluation and management services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery and, therefore, may be billed and paid separately.   In addition to the CPT evaluation and management code, modifier  -57 (decision for surgery) is used to identify a visit which results in the initial decision to perform surgery.  (Modifier  -QI was used for dates of service prior to January 1, 1994.)   If evaluation and management services occur on the day of surgery, the physician bills using modifier  -57, not  -25.  The  -57 modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the  surgery.  Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.  5. Return Trips to the Operating Room During the Postoperative Period   When treatment for complications requires a return trip to the operating room, physicians must bill the CPT code that describes the procedure(s) performed during the return trip.  If no such code exists, use the unspecified procedure code in the correct series, i.e., 47999 or 64999.  The procedure code for the original surgery is not used except when the identical procedure is repeated.   In addition to the CPT code, physicians use CPT modifier  -78 for these return trips (return to the operating room for a related procedure during a postoperative period.)
(Medicare Claims Processing Manual)
In addition to the CPT code, physicians use CPT modifier  -78 for these return trips (return to the operating room for a related procedure during a postoperative period.)   The physician may also need to indicate that another procedure was performed during the postoperative period of the initial procedure.  When this subsequent procedure is related to the first procedure and requires the use of the operating room, this circum stance may be reported by adding the modifier  -78 to the related procedure.   NOTE: The CPT definition for this modifier does not limit its use to treatment for complications.   6. Staged or Related Procedures   Modifier  -58 was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure.  This modifier is not used to report the treatment of a problem that requires a return to the operati ng room.   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.
(Medicare Claims Processing Manual)
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 per formed, 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 reported 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
(Medicare Claims Processing Manual)
 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.