When a patient undergoes surgery with a 90-day global period, the timeline includes the day before surgery, the day of surgery, and the 90 days following the procedure. This creates 92 days within which the global surgical package applies. For example, if surgery is performed on March 3rd, the global period would begin on March 2nd and end on June 3rd.
The normal pre- and post-operative work, including the pre-op visit, is bundled into the surgical package within this period. This means that routine pre-op visits, where only the history and physical (H&P) required by the hospital are discussed, are not separately billable.
However, there are important nuances to consider:
- The decision for Surgery: The global period guidelines from CMS state that “Pre-operative visits after the decision to operate” are included in the global package. If this decision happens before the global period (e.g., weeks before surgery), any pre-op visits that fall between the decision date and the surgery date are typically included in the global package and are not separately billable. (CPT® Assistant – 2009 Issue 5 (May) May 2009 pages 9-10)
- Billing for E/M Services: An evaluation and management (E/M) service can be billed separately if it involves the decision for surgery and occurs the day before or on the day of the procedure. Modifier 57 (Decision for Surgery) should be appended to the E/M code in such cases. However, if the decision has already been made and the visit is purely for pre-op clearance, this visit is part of the global surgical package and is not separately billable.
- Clearance for Surgery: If the documentation shows uncertainty about the patient’s fitness for surgery and further clearance is needed, an additional pre-op visit may be justified and billable, provided the documentation supports this need and shows it’s unrelated or over and above the normal pre-op work on a case by case basis.
As highlighted in the CPT® Assistant May 2009 guidance, routine pre-op clearance visits, regardless of when they occur (1 day, 3 days, or 2 weeks before surgery), are included in the global package and should not be billed separately. Understanding these rules helps ensure accurate billing and compliance with the global surgical package guidelines.
New HCPCS Code G0559
This service involves evaluating a patient during the 90-day global period following a surgical procedure. It is specifically designed for situations where the follow-up is performed by a physician or qualified healthcare professional who:
- Did not perform the original procedure and is not part of the same group practice as the practitioner who performed it.
- May or may not be of the same specialty as the original practitioner.
- Is not operating under a formal transfer of care.
Key Elements of the Service
To bill for this service, the following steps are required, when possible and applicable:
- Review the Surgical Notes:
- Understand the relative success of the procedure, including:
- The anatomy affected.
- Potential complications unique to the patient’s case.
- Understand the relative success of the procedure, including:
- Research the Procedure:
- Determine the expected post-operative course.
- Identify potential complications, particularly if the procedure is outside the physician’s specialty.
- Patient Evaluation:
- Perform a thorough physical examination and assessment to determine whether the post-operative course is progressing appropriately.
- Communicate with the Original Practitioner:
- Address any questions or concerns with the surgeon who performed the procedure.
Billing Considerations
- This service can only be billed once per 90-day global period and is listed in addition to the office or outpatient E/M visit for either new or established patients.
- Proper documentation is crucial to support the additional service, including:
- Details of the surgical notes reviewed.
- Specifics of the research conducted (if applicable).
- Findings from the patient evaluation.
- Any communications with the original practitioner.
Pre Surgical Optimization
Pre-procedural optimization may be necessary in certain cases, particularly for patients with complex chronic conditions requiring interdisciplinary management. This involves ongoing communication among a care team, medication adjustments, and treatment of diabetes or hypertension to optimize the surgical outcome.
For such scenarios, Principal Care Management (PCM) codes (99424-99427) can be used to report these pre-procedural optimization services. These time-based codes focus on managing a single, complex chronic condition that places the patient at significant risk. PCM codes allow for billing of care coordination efforts and non-face-to-face interactions with patients, their families, and other healthcare professionals preparing the patient for surgery. (CPT® Assistant – 2022 Issue 11 (November) November 2022 pages 16-17)
So what are the documentation requirements for PCM?
Principal Care Management (PCM) Services Requirements
PCM Code 99424:
- Service Description: Principal care management services for a single high-risk disease.
- Required Elements:
- The patient has one complex chronic condition expected to last at least 3 months.
- This condition places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death.
- The management of the condition requires development, monitoring, or revision of a disease-specific care plan.
- The condition necessitates frequent adjustments in the medication regimen.
- The condition is unusually complex due to comorbidities.
- Ongoing communication and care coordination are required between relevant practitioners furnishing care.
- Time Requirement: The first 30 minutes of care provided personally by a physician or other qualified healthcare professional per calendar month.
PCM Code 99425:
- Service Description: Principal care management services for a single high-risk disease, continuing from the initial 30 minutes.
- Required Elements:
- It is the same as those listed for PCM code 99424.
- Time Requirement: Each additional 30 minutes of care is provided personally by a physician or other qualified healthcare professional per calendar month.
- Usage: This code is listed separately from the primary procedure and is used to bill extra time spent on care management beyond the initial 30 minutes covered by 99424.
These codes are designed to ensure that complex, chronic conditions requiring intensive and ongoing management are properly documented and billed, ensuring that healthcare providers are compensated for the additional time and coordination required to manage these high-risk patients.
Consider a scenario where a female patient is preparing for elective right total knee arthroplasty (TKA) due to osteoarthritis. This patient also has a history of cardiac arrhythmia and diabetes, and she lives alone. The primary chronic condition being managed is osteoarthritis, which presents a significant risk of complications. While secondary diagnoses like cardiac arrhythmia and diabetes aren’t required to be listed, they are crucial in shaping the optimization plan for surgery.
Coordinated care is essential to enhance the patient’s surgical outcome. This involves scheduling a visit with her cardiologist to address heart-related risks, enrolling her in a diabetes clinic to stabilize her blood sugar levels, and connecting her with a case manager to ensure proper post-surgical care arrangements. These steps require thorough communication between the care team, including the cardiologist, anesthesiologist, and other specialists.
For example, the cardiologist and anesthesiologist will need to discuss any necessary adjustments to her cardiac medications before surgery. Similarly, a coordinated plan for managing her diabetes during the perioperative period must be established. Additionally, a joint education session with the patient’s designated caregiver will help ensure they are prepared to assist with her postoperative care.
Throughout this process, the physician, other qualified healthcare professional (QHP), or clinical staff will document the time spent coordinating these efforts to optimize the patient’s surgical outcome, ensuring that all aspects of her care are aligned and well-managed.
By understanding these options, healthcare providers can more effectively navigate billing and coding practices, ensuring compliance and appropriate reimbursement for the care provided.