||This is the second article in a six-part series that focuses on areas where dermatology is vulnerable, and how members can take action to preserve the ability to practice the full scope of dermatology for the benefit of patients. Watch for the Adapt, Commit, Thrive (ACT) logo in the next four issues of Member to Member to keep abreast of the critical issues facing the specialty in light of health system reform implementation.
By Scott Dinehart, MD
Dermatologists routinely perform procedural services that are subject to 10-day global periods. Most services performed during the global period are not separately reportable with the expectation of receiving separate reimbursement.
However, some services performed during the global period may be reported separately and are payable under certain circumstances. The key to successful global-period claim reporting is understanding the definition of the global surgical package and global periods that apply to the procedure performed. Most 10-day and 90-day global procedures include a post-operative visit, and dermatologists need to diligently document that these follow-up visits have occurred.
During this time of great change in our health care system, understanding the definition and applicability of modifiers typically submitted for services performed during the global period will reduce your risk of an audit. The following points clarify questions you may have about coding for global periods.
Understand all global periods
According to Medicare, “The global surgical package, also called global surgery, includes all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for the surgical procedure includes the pre-operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty.”
When circumstances arise and you have to report services performed during the global period, there are a few guidelines to remember. There are three global period designations:
- 0-day global period: Some procedures, e.g., Mohs surgery, simple repair, and biopsy, have no pre-operative period or post-operative days, and an evaluation and management service (E/M) performed on the same day as the procedure is generally included.
- 10-day global period: Procedures, e.g., excisions, destructions, and intermediate and complex repairs, have no pre-operative period, and an E/M service on the same day as the procedure is generally included. The total global period is 11 days. Count the day of the surgery and 10 days following the day of the surgery.
- 90-day global period: These are major procedures, e.g., flaps and grafts. They include one pre-operative day. The day of the procedure is generally not payable as a separate E/M service, when performed. The total global period is 92 days. Count one day before the day of the surgery, the day of surgery, and the 90 days immediately following the day of surgery.
Note: Check with all of your private payers to familiarize yourself with their specific rules and guidelines regarding global surgical package reimbursement because these vary from payer to payer.
Services included in the global surgical package include pre-, intra-, and post-surgical and medical care, supplies, and any miscellaneous services. Services not included in the global surgical package may include the initial consultation or unrelated evaluation and management (E/M) service.
Note: Medicare will not allow reimbursement for post-operative services that are related to the recovery from a procedure when performed within the global period.
Unrelated E/M service or procedure by the same physician during a post-operative period
There are two modifiers, 24 and 79, that are used to simplify billing for visits and other procedures provided during the post-operative period of a surgical procedure, but are not included in the payment for the surgical procedure.
Note: Guidelines state that both services must be performed by the same physician or group during the global period starting the day after the procedure.
- Modifier 24: An unrelated E/M service by the same physician during a post-operative period. Sometimes, the physician may need to indicate that an E/M service was furnished during the post-operative period of an unrelated procedure. To report such service, modifier 24 must be appended to the appropriate medically necessary E/M service with documentation to support that the service is not related to the post-operative care of the procedure.
Example: You perform an excision of a basal cell carcinoma on Monday and see the patient the next week to treat an unrelated episode of erythema multiforme. You append modifier 24 to the E/M service code.
- Modifier 79: An unrelated procedure or service by the same physician during a post-operative period. You may need to indicate that a procedure or service furnished during a postoperative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.
Example: You perform an excision of an epidermoid cyst on Wednesday. On Friday, during the post-operative period, you see the patient for an unexplained rash and you perform a biopsy. You append modifier 79 on CPT Code 11100-skin biopsy.
It is inappropriate to use modifier 79 to report a staged procedure related to the original procedure that initiated the global period. For staged procedures, see modifier 58.
Coding and scope of dermatology
Paying extra attention to how we are coding for global visits is especially important in this time of great change. Following the guidelines outlined above will help preserve our ability to practice the full scope of dermatology for the benefit of our patients.
Scott Dinehart, MD, is director of Arkansas Skin Cancer Center in Little Rock, Ark. He served as professor at the University of Arkansas for Medical Sciences and director of Mohs and Dermatologic Surgery at Arkansas Cancer and Research Center. He is a past president of the Association of Dermatologic Surgeons.
The Academy has a new manual, "Successfully Managing Modifiers," which is available as an eBook. In addition, the AAD’s updated coding manual, "2014 Coding and Documentation Manual for Dermatology," is available for pre-order. The manual includes easy-to-follow CPT coding tips, as well as an ICD-10-CM codes and implementation overview. Pre-order the coding manual now by calling (866) 503-7546.
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