In the intricate world of medical coding, understanding the nuances of post-operative billing is crucial. Following a surgical procedure, a global surgical package typically encompasses a range of services related to the surgery. However, there are specific instances where services provided during the post-operative period fall outside this global package and can be billed separately. This article clarifies when a post-operative visit is not considered part of the global surgery payment, ensuring accurate coding and billing practices.
Post-operative Services Included in the Global Period
The global surgical package bundles several standard post-operative services into a single payment for a surgical procedure. These commonly included services are often related to routine care and immediate recovery. Understanding what’s included helps to identify what can be billed separately. Services typically bundled within the global period include:
- Routine Wound Care: This encompasses dressing changes and local care at the incision site.
- Removal of Devices: The removal of operative packing, sutures, staples, or other closing materials is considered part of the global package.
- Basic Catheter Management: Insertion, irrigation, or removal of standard urinary catheters, intravenous lines, nasogastric tubes, and rectal tubes are usually included.
- Tracheostomy Tube Removal: Removal of a tracheostomy tube, when part of standard post-operative care, is also bundled.
- Post-operative Pain Management: Routine pain management immediately following surgery is generally included.
- Management of Uncomplicated Post-Surgical Issues: Care for complications arising from the surgery that do not necessitate a return to the operating room is part of the global package. Importantly, locations like a patient’s room, recovery room, intensive care unit (ICU), or a minor treatment room are not classified as operating rooms. Services provided in these locations for uncomplicated issues are not separately billable under the global package.
When Post-Op Care Can Be Billed Separately
Despite the comprehensive nature of the global surgical package, certain post-operative services warrant separate billing. These typically involve care that is either beyond the scope of routine recovery or addresses conditions distinct from the original surgery. Here are key scenarios where separate billing is appropriate, often requiring specific modifiers:
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Subsequent Treatment for the Underlying Condition: If a post-operative visit involves treatment for the original condition requiring further intervention beyond the initial surgery, it can be billed separately. For example, in gynecologic oncology, if a post-operative visit involves discussing or administering chemotherapy, this service is separately billable using modifier -79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period).
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Evaluation and Management (E/M) Services Unrelated to the Surgical Diagnosis: If a patient is seen during the post-operative period for an entirely new or pre-existing health issue that is not related to the surgery, these E/M services are separately billable. Modifier -24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during the postoperative period) should be appended to the E/M code.
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Complications Requiring a Return to the Operating Room: When a post-operative complication necessitates a return to the operating room for an additional procedure, this is billed separately. It’s important to note that the definition of an “operating room” is specific and includes locations like cardiac catheterization suites, laser suites, or endoscopy suites, but excludes patient rooms, recovery rooms, ICUs, or minor treatment rooms. Procedures performed in a true operating room setting to address complications are billed separately using modifier -78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).
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Planned Staged Procedures or More Extensive Procedures: In situations where a staged procedure is planned, or if a more extensive procedure is required following an initial, less extensive one, these subsequent procedures are separately billable. For instance, a radical hysterectomy performed after a conization is considered a staged or more extensive procedure and is separately billable, often with modifier -58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period).
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Post-operative Care Provided by a Non-Surgeon: If a physician who is not the surgeon provides post-operative care (either for the underlying condition or a complication), this care can be billed separately by the non-surgeon. Modifier -55 (Postoperative management only) is used by the original surgeon to indicate they are relinquishing the post-operative care to another provider, and the non-surgeon bills for their services separately.
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Kimberly Levinson MD MPH, expert in gynecologic oncology and surgical coding, explains post-operative billing nuances.]
Navigating post-operative coding requires a detailed understanding of global surgical packages and the specific circumstances that allow for separate billing. Always refer to the Centers for Medicare & Medicaid Services (CMS) guidelines for the most accurate and up-to-date information on global periods and billing regulations. Detailed resources, including downloadable excel files outlining global periods for various procedures, are available on the CMS website and in their comprehensive guide to global surgery, accessible on the CMS website. By correctly applying modifiers and understanding these exceptions, healthcare providers can ensure accurate reimbursement for all billable post-operative services.
