Chapter 4- Denials The Global Surgical Package Flashcards
Global Package as Defined by CPT
Payment for surgical procedures includes a standard package of preoperative, intraoperative, and postoperative services. Preoperative and postoperative periods will differ based on the classifications of the service as a major or minor surgery.
The services included in the global surgical package may be furnished in any service location, for example, a hospital, an ambulatory surgical center (ASC), or physician office. Visits to a patient in an intensive care or critical care unit are also included when made by the surgeon during the global period. Under some circumstances, critical care services (99291–99292) are not considered part of the global package and are reimbursed separately.
Global Package — Non-Medicare Health Plans
Although most health plans have adopted the CMS global package concept, some health plans write variances within their policies. The health plan has leniency to determine if a global period is applicable to surgery procedures. If the health plan determines a global package, it will establish postoperative periods of 0, 10, or 90 days to surgical CPT® codes. Although the number of postoperative period days — 0, 10, or 90 days — remain consistent with Medicare guidelines, the variances of global packages for other health plans should be noted while reviewing patient’s coverage plans.
Surgery as Defined by Medicare
Medicare has classified major and minor surgeries and has determined what services are included and not included with the global package. Medicare also determined the preoperative and postoperative days allowed for each type of surgery.
Surgery as Defined by Medicare
the preoperative period included in the global fee for major surgery is one day with 90 days for the postoperative period. The preoperative period for minor surgery is the day of the procedure with a postoperative period of either 0 or 10 days, depending on the procedure. For endoscopic procedures (except procedures requiring an incision), there is no postoperative period. Global period days are available on the CMS website at www.cms.gov/apps/physician-fee-schedule/overview.aspx.
Surgery as Defined by Medicare
Each CPT® code also has a global period status indicator, as per CMS payment policies. Surgical CPT® codes (10004–69990) have a global surgery status indicator determining classification for a minor or major surgery as determined by RVU calculations. Per the Federal Register, Vol. 74, No. 132, surgical status indicators are assigned based on risk factors associated with medical specialties.
Status Indicators
000 Endoscopies or minor procedures with preoperative and postoperative relative values on the day of the procedure only are reimbursable. E/M services on the same day of the procedure are generally not payable (for example, CPT® 43255, 53020, 67346).
Status Indicators
010 Minor procedures with preoperative relative values on the day of the procedure and postoperative relative values during a 10-day postoperative period are reimbursable services. E/M services on the day of the procedure and during the 10-day postoperative period are not reimbursable (for example, CPT® 17261, 40800, 64612).
Status Indicators
090 Major procedures with one-day preoperative period and 90-days postoperative period are considered to be a component of global package of the major procedure. E/M services on the day prior to the procedure, the day of the procedure, and during the 90-day postoperative period are not reimbursable (for example, CPT® 21048 or 32664).
Status Indicators
MMM Maternity codes; the usual global period concept does not apply (for example, CPT® 59400, 59612).
Status Indicators
XXX The global concept does not apply to this code (for example, E/M services, anesthesia, laboratory, and radiology procedures) (for example, CPT® 10021, 36593, 38220, 44720).
Status Indicators
YYY These are unlisted codes, subject to individual pricing (for example, CPT® 19499, 20999, 44979).
Status Indicators
ZZZ These represent add-on codes. They are related to another service and are always included in the global period of the primary service (for example, CPT® 27358, 44955, 67335).
Services Included in the Global Package
- Preoperative Visits — Preoperative visits on the day before or day of a major procedure, and pre-operatives performed on the day of for a minor procedure
2.Intraoperative Services — Intraoperative services considered a usual and necessary part of a surgical procedure, such as the use of local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia
3.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
4.Postoperative Visits — Follow-up visits within the postoperative period of the surgery, related to recovery from the surgery
5.Postsurgical Pain Management — By the surgeon
6.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
Services Not Included in the Global Package
1.Initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.
2.Visits unrelated to the diagnosis for which the surgical procedure was performed, unless the visits occurred due to complication of the surgery.
3.Treatment for the underlying condition or an added course of treatment that is not part of the normal recovery from surgery.
4.Diagnostic tests and procedures, including diagnostic radiological procedures.
5.Clearly distinct surgical procedures during the postoperative period that 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 which the decision to stage the procedure is made prospectively or at the time of the first procedure.
6.Treatment for postoperative complications requiring a return trip to the operating room (OR). The term operating room includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition is so critical that there is not sufficient time for transportation to an OR).
7.If a less extensive procedure fails and a more extensive procedure is required, the second procedure is payable separately.
8.Certain services performed in a physician’s office.
9.Immunosuppressant therapy management for organ transplants.
10.Critical care services (codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.
11.The Medicare program will not pay separately for an E/M service on the same day as a minor surgery or endoscopy, unless a significant, separately identifiable service is also performed (for example, an initial consultation or initial new patient visit).
Maternity Care and Delivery Global Package
The codes in the Maternity Care and Delivery subsection are used to describe services related to antepartum, delivery, and postpartum care.
There are four codes for the global delivery package:
59400 is for the global package including vaginal delivery.
59510 is for the global package including cesarean delivery.
59610 and 59618 are for global delivery when the patient has had a previous cesarean delivery but now labors to deliver vaginally. Report 59610 if the baby is delivered vaginally, and 59618 if delivered by cesarean after trying to delivery vaginally. Do not use these codes if there is no period of labor prior to delivery.
