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September 13, 2012

Submitting Evaluation & Management (E/M) Services Separately from the Global Surgery Package

The CMS global surgery package defines the services included in a surgical payment as well as services that are excluded from (and that may be reimbursed in addition to) the surgical payment. E/M services that are included in the global surgery package may not be reported separately.

E/M services that are identified as separate from the global package may be submitted separately. The patient's record must clearly document and support these services.

There are a few steps to remember:

  • Step 1: Understand all global periods. There are three global period designations: same day (000), minor (010, 10 days), and major (090, 90 days). The global period for all major global periods includes the day before the procedure, the day of the procedure, and 90 days after the procedure. Global periods for all surgical procedures are identified in the Medicare Physician Fee Schedule Database (MPFSDB)External Website.
  • Step 2: Review the beneficiary's record to determine whether the E/M service falls within the global period. (If no global periods are found, do not submit a global modifier with the E/M service.)
  • Step 3: If a global period is found, identify the type of global period: same day (000), minor (010), or major (090).
  • Step 4: Review the beneficiary's records to ensure the E/M services are significant and separate or unrelated by the same physician from the global procedure in history. Per the CPT® Assistant handbook: "The E/M service is generally unrelated to the procedure or service being provided but may, on occasion, be prompted by the symptom or condition for which the procedure and/ or service was provided."
  • Step 5: Once the E/M is identified as significant and separate or unrelated by the same physician, select the appropriate modifier to submit with the E/M service.
Modifiers typically submitted with E/M codes during the global period are defined in the AMA CPT® manual.
CPT Modifier Description Tips
24 Unrelated E/M by the Same Physician during a Postoperative Period
  • Submit only with E/M services that are unrelated to the reason for surgery, when the E/M service falls within the postoperative period
  • An ICD-9 code unrelated to the reason for surgery may be sufficient documentation with the claim
  • If the ICD-9 code does not clearly establish the E/M service as unrelated to the reason for surgery, submit additional narrative documentation in the electronic notepad field (or in Item 19 of the CMS-1500 claim, if you meet the requirements to submit paper claims)
25 Unrelated E/M by the Same Physician during a Postoperative Period

Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of a Procedure or Other Service
  • Submit only with E/M services performed on the same day as a minor surgery (0- or 10-day global period) when the E/M service is unrelated to the reason for surgery
57 Decision for Surgery; used with E/M service that resulted in the initial decision to perform the surgery
  • Submit only with E/M services performed during the global period (day before, day of, or 90 days after) of a major surgery

Examples: Submitting Global Surgery Modifiers with E/M Services

CPT modifier 24: A beneficiary was seen by Dr. J. for closed treatment of a humeral fracture (CPT code 24500, 90-day global period) on July 1. On August 3, the same beneficiary saw Dr. J. in the office again for management of his diabetes. Documentation supports submitting CPT code 99213 for this service:

  • The E/M service is unrelated to treatment performed on July 1.
  • CPT modifier 24 is necessary because visit is within the 90-day global period.

CPT modifier 25: A beneficiary visited Dr. B. to have a lesion removed (CPT code 17270 (10-day global period), from her arm. During the procedure, she mentioned she has been experiencing some dizziness and shortness of breath during normal day-to-day activity. Dr. B. insists that they talk about her symptoms and run some additional tests.

  • The E/M service is unrelated to the lesion removal.
  • CPT modifier 25 is appropriate because the service was performed on the same day as a minor surgery (as defined in the MPFSDB) and is not included in the global surgery package.

CPT modifier 57: A beneficiary visited Dr. H. due to significant lower abdominal pain that began a week prior to the visit. After an exam of the patient, Dr. H. diagnosed the beneficiary with acute appendicitis and performed a laparoscopic appendectomy (CPT 44970, 90-day global period) later that day.

  • This visit resulted in the initial decision to have surgery and is therefore separately payable.
  • CPT modifier 57 is appropriate in this case.

Reference:


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