CurrentArizona Complete HealthPolicy CC.PP.040

Payment Policy: Visits On Same Day As Surgery

Defines payment and billing rules for E&M services performed on the same day as surgical procedures for Arizona Complete Health members across all product types; governs how E&M codes billed with surgical global periods are evaluated and when they are separately reimbursable.

Policy Summary

PayerArizona Complete Health

PolicyPayment Policy: Visits On Same Day As Surgery

Policy CodePolicy CC.PP.040

Change TypeNo material change

Effective DateMar 1, 2018

Next Review Date

Key ActionDo not separately bill E&M services included in the global surgical package; append modifier -25 or -57 with supporting documentation when exceptions apply.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

000,010,090,MMM,ZZZGlobal indicators

-25, -57Modifiers reviewed

RN/coder reviewPrepayment validation

4Settings covered

90-dayMajor global period

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Same-day E&M with Surgery — Coverage Criteria

Coverage criteria for same-day E&M services

E&M services performed on the same day as surgical procedures are generally included in the global surgical package and not separately reimbursable unless specific exceptions apply.

E&M services occurring on the same day as a surgical procedure are included in the global surgical reimbursement package and will not be separately reimbursed for procedures with global indicators 000, 010, 090, MMM, or ZZZ.

Exceptions (ONE of)

E&M visit is significant and separately identifiable from the reason for surgery; provider appends modifier -25 and submits supporting documentation; claim will undergo RN/coder prepayment validation and may be paid if supported.
E&M service resulted in the decision to perform a major surgery (90-day global) on the day prior to or the day of surgery; provider appends modifier -57 and submits supporting documentation; claim will undergo prepayment validation and may be paid if supported.

Claims editing will evaluate claim lines, procedure codes, diagnosis codes and modifiers across claim lines and patient history; E&M claim lines billed same day as surgery will be denied unless validated by consideration of modifiers -25 or -57 and supporting documentation.

Policy applies to inpatient, outpatient, ambulatory surgical center and physician E&M services involving the global surgical package.

Coverage and billing rules

Stance on billing E&M services related to surgical global periods and documentation expectations.

E&M services that are part of the global surgical package are included in the surgical payment and generally not separately reimbursed.

When billing E&M services that are permitted to be billed separately, providers must document history, physical examination, medical decision-making, counseling, coordination of care, nature of the presenting problem and time in accordance with CPT guidance.

Pre-operative visits: for major procedures include the day before and the day of surgery; for minor or endoscopic procedures include E&M services on the day of surgery.

For Medicaid members, state Medicaid coverage provisions take precedence over this policy when conflicts exist; for Medicare members, applicable NCDs and LCDs should be reviewed prior to applying this policy.

Codes, Modifiers, and Denial Rules

Representative E&M and modifier codesCPT | Modifier

99211-99215	E&M Office and Other Outpatient Services (established patient)
99291-99292	Critical Care Services
-25	Significant, Separately Identifiable E&M on same day of procedure
-57	Decision for surgery (E&M resulted in decision to perform surgery)

E&M CPT codesCPT

99224-99226

New or added inpatient/outpatient subsequent hospital care codes referenced as added in policy revision history

inv-05: Same-day denial rule

RuleE&M codes billed on the same day as a minor, major, maternity or ZZZ procedure will be denied as included in the global surgical package unless supported.

Modifiers ReviewedModifiers -25 and -57 are considered prior to a denial determination; documentation must support separate reimbursement.

Scope of ReviewClaims editing reviews claim lines on the same claim and across claims in the patient history and across dates of service.

inv-06: global_surgical_period

Major Procedure Global Period90-day post-operative period (total global period = 92 days including one day pre-op and day of surgery).

Minor Procedure Global Periods000 (zero-day) or 010 (10-day) post-operative periods; 000 applies only to same-day visits, 010 includes day of surgery plus 10 days following.

Maternity (MMM) Global PeriodAntepartum period of 270 days; same-day delivery included; 45-day post-partum period following delivery.

Billing, Documentation, and Appeals

Denial Risk

Prepayment review and appeals

Claims containing E&M codes billed on the same day as a minor, major or maternity procedure will be denied as those services are considered included in the payment for the surgical procedure. Modifiers -25 and -57 will be reviewed prior to a denial determination. If you disagree with a prepayment claims edit, submit an appeal or reconsideration request with all supporting medical record documentation per health plan rules.

E&M same-day claim lines will be denied unless validated.
Modifiers -25 and -57 are evaluated before denial.
Appeals/reconsiderations require full medical record documentation to accompany the request.

Billing Rule

Billing rule and documentation requirements

Do not separately bill E&M services that are part of the global surgical package; E&M services billed on the day of a minor, major or maternity procedure are considered included in the surgical payment. When billing permitted E&M services, document history, exam, medical decision-making, counseling, coordination of care, presenting problem and time as required by CPT guidance.

Global surgical package includes all pre‑operative, intra‑operative and post‑operative services routinely performed by the surgeon or same‑specialty group.
Pre‑operative visits for major surgery include the day before and the day of surgery; for minor/endoscopic procedures include E&M services on the day of surgery.
Document E&M encounters per CPT: history, physical exam, medical decision‑making, counseling, coordination of care, presenting problem and time.

Key Definitions

inv-09: Global surgical package — definition

DefinitionAll necessary services normally furnished by a surgeon before, during and after a procedure; payment for the surgical procedure includes pre-operative, intra-operative and post-operative services routinely performed by the surgeon or same-specialty group.

Included ServicesIncludes evaluation and management services, anesthesia, immediate post-operative care, written orders, and evaluation in the post-anesthesia recovery area.

ApplicabilityApplies to services performed routinely by the surgeon or members of the same surgical group with the same specialty.

inv-10: Global surgical period types (000,010,090,MMM,ZZZ)

000 (zero-day)Global period applies only to visits and services that occur on the same day as the surgery; same-day E&M not separately reimbursed unless significant and separately identifiable with modifier -25.

010 (10-day)E&M services occurring within 10 days of surgery are included in the global package; total global period = 11 days (day of surgery counts as day one).

090 (90-day), MMM, ZZZ090 = major procedures (includes one day pre-op and day of surgery); MMM = maternity global including antepartum and 45-day postpartum; ZZZ = add-on procedures billed with primary procedure.

inv-11: Global Surgical Package

What it isThe Global Surgical Package bundles pre-operative, intra-operative and post-operative services into the payment for the surgical procedure.

ComponentsIncludes routine pre-op evaluation, intra-operative services, immediate post-operative care, written orders and typical postoperative follow-up care.

Payment ImplicationE&M services that are part of the global package are generally not separately reimbursed; claims edits evaluate for same-day billing.

inv-12: E&M Service

DefinitionEvaluation and Management (E&M) services are physician-patient encounters represented by five-digit CPT codes requiring documentation of history, exam, medical decision-making, counseling, coordination of care and time.

Documentation RequirementPhysicians must document medical history, physical exam, medical decision-making, counseling, coordination of care and time spent as applicable to the CPT code billed.

Coding ContextCPT codes are used for billing Medicare, Medicaid, Marketplace or private insurance encounters and are referenced by the policy.

inv-13: Major Procedure

DefinitionMajor Procedure: a procedure defined as one with a 90-day global surgical period.

Reimbursement ImpactE&M visits on the day prior to or the day of a major surgery are included in the global period unless modifier -57 documents a decision for surgery.

Global Period LengthTotal global period for major procedures is 92 days (one day pre-op, day of surgery, plus 90 post-op days).

inv-14: Minor Procedure

DefinitionMinor Procedure: a procedure or endoscopy defined as one with a 000 (zero-day) or 010 (10-day) global surgical period.

000-Day Rule000-day global period applies only to services on the same day as surgery; same-day E&M included unless significant and separately identifiable with -25.

010-Day Rule010 global period means E&M services occurring within 10 days post-op are included; total global period is 11 days with day of surgery as day one.

inv-15: Pre-operative Period

DefinitionPre-operative Period: the day before or the day of the procedure; for major surgery includes the day before and the day of surgery; for minor procedures includes E&M services on the day of surgery.

Decision for SurgeryE&M services on the day before or day of major surgery that result in the decision to perform surgery may be separately reimbursable with modifier -57 and documentation.

No Pre-op for SomeThe global concept does not apply to visits rendered the day prior to a surgical procedure in certain minor surgery contexts (policy notes no pre-operative period for some types).

inv-16: Post-operative Period

DefinitionPost-operative Period: care beginning at the end of the operation, in the recovery room, throughout the hospitalization and the outpatient follow-up period.

Inclusion in GlobalE&M services occurring during the post-operative period defined by the procedure's global days are generally included in the surgical payment and not separately reimbursable.

Duration ExamplesMinor: 0 or 10 days post-op; Major: 90 days post-op; Maternity: 45 days post-partum.

inv-17: Intra-operative Period

DefinitionIntra-operative Period: services carried out as part of the normal and necessary surgical service during the course of surgery.

InclusionThese services are components of the global surgical package and are not separately billable.

ExamplesServices performed during surgery, as routinely provided by the surgeon, are included in the procedure payment.

inv-18: Antepartum Period

DefinitionAntepartum Period: the period occurring before childbirth; maternity global includes antepartum care over 270 days as the preoperative period.

Maternity InclusionVisits that occur during the antepartum period or on the same date of delivery are included in the global maternity package and not separately reimbursed.

Post-partumMaternity global includes a 45-day post-partum period during which E&M services are generally included in the global payment.