Suggest Strategies For Accurate Application Of The Global Surgical Package

Strategies for Accurate Application of the Global Surgical Package

The global surgical package is a cornerstone of surgical coding and reimbursement, a concept crucial for healthcare providers, coders, and billers involved in surgical procedures. A deep understanding of its components and correct application are vital to ensuring fair compensation and avoiding compliance issues. This article delves into the intricacies of the global surgical package, offering practical strategies for its accurate and consistent implementation.

Understanding the Global Surgical Package

At its core, the global surgical package, defined by the Centers for Medicare & Medicaid Services (CMS), represents a bundled payment that encompasses all the necessary services typically provided to a patient undergoing a surgical procedure. This single payment covers not only the surgery itself but also a range of related services before, during, and after the operation.

• The intent: The global surgical package is intended to streamline billing and payment processes, promoting efficiency and reducing administrative burden for both providers and payers. It also aims to ensure that patients receive comprehensive care without facing unexpected or fragmented bills.

Components of the Global Surgical Package:

To effectively apply the global surgical package, it is essential to understand the specific services included within it. Generally, the package encompasses the following:

1. Preoperative Services: This includes the initial evaluation and management (E/M) services provided to the patient before the surgery. This may include:
   • The history and physical examination
   • Ordering and reviewing diagnostic tests
   • Patient education and counseling related to the surgical procedure.
2. Intraoperative Services: This segment covers the surgical procedure itself, including:
   • The surgeon's services during the operation
   • Standard anesthesia services
   • Usual intraoperative supplies
3. Postoperative Services: This portion includes all routine follow-up care provided to the patient after the surgery for a specific period, known as the global period. Common postoperative services include:
   • Wound care
   • Dressing changes
   • Removal of sutures or staples
   • Routine follow-up visits to monitor the patient's recovery.

Defining the Global Period:

The global period is a critical component of the global surgical package. It is the specified timeframe during which postoperative services related to the surgery are included in the global payment. CMS defines two primary global periods:

• 0-Day Global Period: Procedures with a 0-day global period typically involve minor procedures with minimal postoperative care. Follow-up visits on the same day as the procedure are usually included in the global payment.
• 10-Day Global Period: Procedures with a 10-day global period involve minor to intermediate procedures. Postoperative visits within ten days following the surgery are included in the global payment.
• 90-Day Global Period: Procedures with a 90-day global period usually involve major surgeries. Postoperative visits within 90 days following the surgery are included in the global payment.

Strategies for Accurate Application

Accurately applying the global surgical package is critical for ensuring proper reimbursement and avoiding potential billing errors. The following strategies can help healthcare providers and coding professionals navigate the complexities of the global surgical package:

1. Determine the Correct CPT Code: The Current Procedural Terminology (CPT) code accurately identifies the specific surgical procedure performed. Proper code selection is paramount as it determines the applicable global period.
2. Verify the Global Period: Once the CPT code is identified, confirm the assigned global period. CMS provides resources, such as the Medicare Physician Fee Schedule Database (MPFSDB), that list the global period for each CPT code.
3. Understand the Inclusions: Know which services are included in the global surgical package: preoperative, intraoperative, and postoperative.
4. Identify Exceptions and Modifiers: Be aware of situations that may warrant separate billing outside the global surgical package. Use appropriate CPT modifiers to indicate when a service should be billed separately.
5. Document Thoroughly: Detailed and accurate documentation is essential. Ensure that the medical record clearly supports the services provided, the reason for any additional services, and the use of modifiers.

Let's explore each of these strategies in depth.

1. Determine the Correct CPT Code

The foundation of accurate global surgical package application is selecting the right CPT code. This code acts as the key to unlocking all the information needed for correct billing.

• Specificity is Key: Choose the CPT code that most accurately reflects the work performed by the surgeon. Avoid using generic or "unlisted" codes when a more specific code is available.
• Coding Guidelines: Consult the CPT codebook for detailed descriptions, coding guidelines, and parenthetical notes that provide guidance on proper code selection.
• Operative Report: The operative report is your primary source of information. Scrutinize every detail of the report, paying close attention to:
  • The surgical approach (e.g., open, laparoscopic, endoscopic)
  • The anatomical site
  • The procedures performed
  • Any additional procedures or services rendered during the surgery.

Example:

Suppose a surgeon performs a laparoscopic cholecystectomy (gallbladder removal). The correct CPT code would be 47563 (Laparoscopy, surgical; cholecystectomy). Using a less specific code could lead to incorrect global period assignment and reimbursement issues.

2. Verify the Global Period

Once the correct CPT code is determined, the next crucial step is to verify the assigned global period.

• Medicare Physician Fee Schedule Database (MPFSDB): The MPFSDB, available on the CMS website, is the most reliable source for determining the global period for a specific CPT code. You can search the database by CPT code to find the assigned global period indicator.
• Coding Software: Many coding software programs integrate the MPFSDB information, allowing you to quickly access the global period for a given CPT code.
• Beware of Variations: Be aware that global periods can vary depending on the payer (e.g., Medicare, Medicaid, commercial insurance). Always verify the global period with the specific payer before submitting the claim.

3. Understand the Inclusions

Comprehending what is included within the global surgical package is paramount to prevent unbundling, which is billing separately for services that are considered part of the package.

• Preoperative Visits: Generally, one E/M visit before the day of surgery is included in the global surgical package, when the decision to perform the surgery is made. If the E/M visit and the surgery occur on the same day, and the decision for surgery was made during the visit, modifier -25 should be appended to the E/M code.
• Intraoperative Services: The surgical procedure itself, including standard anesthesia and typical intraoperative supplies, is included in the global payment.
• Postoperative Visits: Routine postoperative care, such as wound checks, suture removal, and uncomplicated follow-up visits within the global period, are included in the global surgical package.

4. Identify Exceptions and Modifiers

While the global surgical package encompasses a wide range of services, specific exceptions exist that allow for separate billing. Proper use of CPT modifiers is essential in these situations.

Common Scenarios for Separate Billing:

• Significant, separately identifiable E/M service: If the patient requires a significant and separately identifiable E/M service that is unrelated to the surgical procedure, it can be billed separately using modifier -25. For example, if a patient undergoing cataract surgery also presents with an acute respiratory infection, the E/M service for the respiratory infection can be billed separately.
• Return to the operating room for a related procedure: If the patient needs to return to the operating room during the postoperative period for a related procedure, modifier -78 should be appended to the CPT code for the second procedure. This indicates that the second procedure is related to the initial surgery but requires a return to the operating room.
• Staged or related procedure during the postoperative period: When a staged or related procedure is performed during the postoperative period of the initial procedure, modifier -79 should be appended to the CPT code for the subsequent procedure. This indicates that the procedure is related but planned or staged.
• Unrelated E/M service during the postoperative period: If the patient requires an E/M service for a condition entirely unrelated to the surgery during the postoperative period, it can be billed separately using modifier -24.
• Complications Requiring Additional Services: If complications arise post-surgery that necessitate significant additional services beyond routine post-operative care, these services may be billable separately. Clear documentation is key.

Common Modifiers Used with the Global Surgical Package:

• Modifier -24: Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period.
• Modifier -25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of a Procedure or Other Service.
• Modifier -58: Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period.
• 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.
• Modifier -79: Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period.

5. Document Thoroughly

Comprehensive and accurate documentation is the cornerstone of compliant and accurate billing. Without clear documentation, supporting separate billing or the use of modifiers becomes challenging.

• Detailed Operative Report: The operative report should include all relevant details of the surgical procedure, including the approach, anatomical site, procedures performed, and any complications encountered.
• Clear E/M Documentation: For E/M services billed separately, the documentation must clearly demonstrate that the service was significant, separately identifiable, and unrelated to the surgical procedure.
• Justification for Modifiers: When using modifiers, the documentation must clearly support the reason for the modifier. For example, if using modifier -25, the documentation should explain why the E/M service was significant and separately identifiable.
• Legible and Complete Records: Ensure that all medical records are legible, complete, and accurately reflect the services provided.

Additional Strategies for Success:

1. Stay Updated: Coding guidelines and regulations are constantly evolving. Stay informed about the latest changes by:
   • Subscribing to industry newsletters and publications
   • Attending coding seminars and workshops
   • Regularly reviewing CMS transmittals and updates
2. Conduct Regular Audits: Perform internal audits of surgical coding and billing practices to identify potential errors and areas for improvement.
3. Provide Training: Ensure that all coding and billing staff receive comprehensive training on the global surgical package and related coding guidelines.
4. Utilize Coding Resources: Leverage coding resources such as coding software, online coding tools, and coding reference books to enhance accuracy and efficiency.
5. Communicate Effectively: Foster open communication between surgeons, coding staff, and billing staff to address questions and resolve coding issues promptly.

Common Errors to Avoid:

1. Unbundling: Billing separately for services that are included in the global surgical package.
2. Incorrect Modifier Usage: Using modifiers inappropriately or without proper documentation.
3. Failure to Document: Insufficient or inadequate documentation to support billing practices.
4. Ignoring Payer-Specific Guidelines: Failing to adhere to specific payer guidelines regarding the global surgical package.
5. Using Outdated Information: Relying on outdated coding guidelines or regulations.

FAQ

• What if a patient sees a different physician for postoperative care?

  If a patient receives postoperative care from a physician who is not in the same group practice as the surgeon, the physician providing the postoperative care can bill for their services using modifier -24 if the services are unrelated to the surgery, or modifier -55 if they are providing routine post-operative care that was transferred to them. The surgeon would then bill for the surgery with modifier -54 (Surgical Care Only).

• How do I handle supplies used during the surgery?

  Standard surgical supplies used during the procedure are included in the global surgical package. However, certain high-cost items or specific supplies may be billable separately if they meet the payer's criteria for separate billing.

• What if the surgery is canceled after the patient is prepped and draped?

  In this scenario, you may be able to bill for a portion of the surgical service, depending on the payer's guidelines. Modifier -53 (Discontinued Procedure) may be appropriate. Thorough documentation is essential.

• Are diagnostic procedures performed during the postoperative period included in the global surgical package?

  Diagnostic procedures performed during the postoperative period are generally billable separately, unless they are directly related to the surgical procedure and considered part of the routine postoperative care.

Conclusion

Accurate application of the global surgical package is essential for compliant and efficient surgical coding and billing. By understanding the components of the package, utilizing appropriate coding strategies, and staying informed about the latest guidelines, healthcare providers and coding professionals can ensure fair reimbursement and avoid potential billing errors. Diligence, continuous education, and clear communication are vital to navigating the complexities of the global surgical package and optimizing revenue cycle management.