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E/M Visits More Than a Day Before Surgery May Be Part of Global Period, AMA States

June 30, 2015:

For those used to considering services provided more than a day before surgery as separately reportable because they are not part of the global surgical package, recent clarification by the American Medical Association will come as a surprise.

Evaluation and management services related to the surgery but performed more than a day—even weeks—before the operation may not be separately reportable when performed after the decision for surgery is made, according to the March 2015 issue of the CPT Assistant.

As an example, the article cites a case in which the decision for surgery is made on March 1, with the operation itself scheduled for April 1. The patient then visits the office March 27, five days before surgery, for the history and physical and signing of the consent form. According to the AMA, the March 1 visit is billed with modifier 57 Decision for Surgery, but the second visit is not reported, as it is part of the surgical package.

The article explains that it is the intent of the visit, not necessarily when it occurs, that is important. If the visit occurs after the decision for surgery is made and its intent is preoperative H&P, it is not separately reportable "regardless of when the visit occurs [e.g., 1 day, 3 days, or 2 weeks]" before the operation itself.

CPT Surgical Package Definition
By their very nature, the services to any patient are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. In defining the specific services “included” in a given CPT surgical code, the following services related to the surgery when furnished by the physician or other qualified health care professional who performs the surgery are included in addition to the operation per se:

  • Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)
  • Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
  • Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals
  • Writing orders
  • Evaluating the patient in the postanesthesia recovery area
  • Typical postoperative follow-up care

Payers may or may not follow AMA guidelines. Medicare still classifies global surgical packages into three types, depending on the number of postoperative days.

Zero day postoperative period (endoscopies and some minor procedures): No preoperative period and no postoperative days. A visit on the day of the procedure is generally not payable as a separate service .

10-day postoperative period (other minor procedures): No preoperative period. A visit on the day of the procedure is generally not payable as a separate service. The total global period is 11 days, counting the day of the surgery and 10 days following the day of the surgery.

90-day postoperative period (major procedures): One day preoperative included, and a visit on the day of the procedure is generally not payable as a separate service. The total global period is 92 days, counting one day before the day of the surgery, the day of surgery, and the 90 days immediately following the day of surgery. For more information, refer to the Medicare Claims Processing Manual, chapter 12, sections 40 and 40.1, at http://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/downloads/clm104c12.pdf on the CMS website.

As with any guidelines with more than one possible interpretation, it is a good idea to check with each payer when submitting bills with E/M visits related to surgery but provided more than a day before the procedure.


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