California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.16.2 - Surgery - Billing Requirements for Global Surgeries

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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 included in the global
						package.
(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 (rendering) physician.
(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.
Physicians 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 beneficiary's 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" modifier for the
						post-discharge care. The surgeon bills the surgery code with the "-54"
						modifier.
* 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 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.
If evaluation and management services occur on the day of
						surgery, use 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 is not separately payable in addition
						to the procedure.
(5) Return
					 Trips to the Operating Room During the Postoperative Period for Treatment of
					 Complications.
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
						unlisted procedure code in the correct series, e.g., 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, use CPT modifier "-78" for
						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, report this circumstance by adding
						the modifier "-78" to the related procedure.
(6) Staged or Related Procedures. Use
					 modifier "-58" for 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 operating room.
Modifier "-58" is added to the staged procedure when 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.
A new postoperative period begins when the next procedure
						in the series is billed.
(7) Unrelated Procedures or Visits During the
					 Postoperative Period.
CPT modifiers "-79" and "-24" are used 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.
(A) Modifier "-79" reports
					 an unrelated procedure by the same physician during a postoperative period. A
					 new postoperative period begins with the unrelated procedure.
(B) Modifier "-24" reports an unrelated
					 evaluation and management service by same physician during a postoperative
					 period. 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 documentation. A physician who is
					 responsible for postoperative care using modifier "-55" should also use
					 modifier "-24" to report any unrelated visits.
(8) Significant Evaluation and Management on
					 the Day of a Procedure. Modifier "-25" is used for 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 the 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 patient's 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.
(9) Critical Care.
					 Critical care services provided during a global surgical period for a seriously
					 injured or burned patient are not considered related to a surgical procedure
					 and may be paid separately under the following circumstances. Preoperative and
					 postoperative critical care may be paid in addition to a global fee if:
(A) The patient is critically ill and
					 requires the constant attendance of the physician; and
(B) The critical care is above and beyond,
					 and, in most instances, unrelated to the specific anatomic injury or general
					 surgical procedure performed.
Such patients are potentially unstable or have conditions
						that could pose a significant threat to life or risk of prolonged
						impairment.
In order for these services to be paid, two reporting
						requirements must be met:
* Codes 99291/99292 and modifier "-25" (for preoperative
						care) or "-24" (for postoperative care) must be used; and
* Documentation that the critical care was unrelated to
						the specific anatomic injury or general surgical procedure performed must be
						submitted. A diagnosis which clearly indicates that the critical care was
						unrelated to the surgery, is acceptable
						documentation.
(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."