CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Billing and Reimbursement Guideline: Surgical Global Fee Period

Guideline governing coding, documentation, and reimbursement for surgical global periods and related modifiers for Neighborhood Health Plan of Rhode Island providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBilling and Reimbursement Guideline: Surgical Global Fee Period

Policy CodePolicy N/A

Change TypeFormat change, minor edits (9/1/2013)

Effective DateSeptember 1, 2010

Next Review DateN/A

Key ActionDocument the decision for surgery and bill E/M with modifier 57 (major) or modifier 25 (minor) when applicable.

SourceLink

POLICY UPDATE CHANGES

Format change, minor edits (revision date 9/1/2013).

90-daypostoperative period for major surgeries per Medicare PFS designation

0-10 dayglobal period range for minor procedures and endoscopies

2original publish and recorded revision

Surgical Global Period Coverage Criteria

Surgical global period coverage criteria

Covered separately only when the following documentation and coding conditions are met:

ALL of the following

Decision for surgery must be clearly documented in the medical, hospital, or office record.
Decision-for-surgery coding (choose one)
- If the decision for surgery is made at the time of a consultation or other E/M during the preoperative period for a major procedure, bill the E/M with modifier 57 to indicate the decision for major surgery.
- If the decision for surgery occurs when a minor procedure is performed (0- or 10-day global period), bill the E/M with modifier 25 to indicate the decision for surgery.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBilling and Reimbursement Guideline: Surgical Global Fee Period

Policy CodePolicy N/A

Change TypeFormat change, minor edits (9/1/2013)

Effective DateSeptember 1, 2010

Next Review DateN/A

Key ActionDocument the decision for surgery and bill E/M with modifier 57 (major) or modifier 25 (minor) when applicable.

SourceLink

On This Page

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ALL of the following

Services that are considered included in the surgical global package and are not separately reimbursable include: preoperative visit on the day before or day of surgery; local/topical anesthesia administered by the surgeon; associated same-day biopsies; routine intra-operative care; routine postoperative care during the assigned global period; and treatment of complications not requiring return to the operating room.
When a separately identifiable service during the global period may be billed
- Unrelated E/M services during the postoperative period should be billed with modifier 24 and an appropriate supporting diagnosis.
- Distinct procedural services should be reported with modifier 59.
- Return to the operating room for a related procedure during the postoperative period should be reported with modifier 78.

Documentation and Modifier Usage — Provider Actions

Documentation Required

Clinical documentation review

Operative notes may be requested to review services denied as inclusive in a surgical package. Ensure documentation clearly supports any separate service billed during a global period (for example, an unrelated E/M or procedure).

Operative notes should document why the service is distinct from the global surgical package.
Unrelated services during a global period must include an appropriate supporting diagnosis and modifier to be considered for payment.
This guideline applies to both CMS-1500 and UB-92 claim submissions.

Billing Rule

Modifier usage for decision and separate services

Use modifiers to indicate when evaluation/management or other services are separately payable from the surgical global package. Modifier 57 denotes the decision for surgery when an E/M during the preoperative period results in the initial decision for a major procedure. Modifier 25 denotes a significant, separately identifiable E/M on the same day as a minor procedure. For services during a global period that are unrelated and separately billable, use appropriate modifiers (for example, 24, 59, or 78) and document the separate nature of the service.

Modifier 57: E/M during preoperative period leading to decision for a major surgery (90-day global) — indicates decision for surgery.
Modifier 25: Significant, separately identifiable E/M on the same day as a minor procedure (0- or 10-day global).
Modifiers 24, 59, 78: Use to indicate unrelated or distinct services during the global period when applicable.

Definitions — Major/Minor Procedures and Modifiers

Major surgeries: definition

DefinitionMajor surgeries are procedure codes identified in the Medicare Physician Fee Schedule Data Base with a 90-day postoperative period.

Minor procedures and endoscopies: definition

DefinitionMinor procedures and endoscopies have a zero to ten global period.

Modifier 57: definition

Modifier 57 — purposeIndicates the physician provided an evaluation and management (E/M) service during the preoperative period for a major procedure that resulted in the initial decision for surgery.

When to useUse when decision for major surgery is made at time of consultation or other E/M during the preoperative period.

Documentation requirementDecision for surgery must be clearly documented in the medical, hospital, or office record.

Modifier 25: definition

Modifier 25 — purposeUsed to indicate decision for surgery when a minor procedure is performed (0 or 10 day global period).

When to useUse when a minor procedure is performed and an E/M service represents a separately identifiable decision for surgery.

Documentation requirementDecision for surgery must be clearly documented in the medical, hospital, or office record.

Modifier 57	Indicates E/M service resulting in the initial decision for major surgery
Modifier 25	Indicates decision for surgery when a minor procedure is performed (0 or 10 day global period)
Modifier 24	Unrelated E/M service during a postoperative period
Modifier 59	Distinct procedural service
Modifier 78	Return to the operating room for a related procedure during the postoperative period

OpenPayer

Billing and Reimbursement Guideline: Surgical Global Fee Period

Surgical Global Period Coverage Criteria

Modifiers and Coding Related to Global Periods

Documentation and Modifier Usage — Provider Actions

Definitions — Major/Minor Procedures and Modifiers