If you’re like most family physicians, your practice includes some surgical procedures (e.g., integumentary procedures, fracture care, vasectomy). Consequently, understanding what services are included in the surgical package, what constitutes the global surgical period and how to code any related or unrelated services in the global surgical package is critical to making sure you get paid appropriately.

CPT’s surgical package

According to CPT, the surgical package includes the following:

• The surgical procedure;

• Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia;

• One related evaluation and management (E/M) encounter (including history and physical) that occurs after the decision for surgery has been made and is either on the date immediately prior to the procedure or on the actual date of the procedure;

• Immediate postoperative care, including dictating operative notes and talking with the family and other physicians;

• Writing orders;

• Evaluating the patient in the postanesthesia recovery area;

• Typical postoperative follow-up care.

CPT states that “typical postoperative follow-up care” includes “only that care which is usually a part of the surgical service. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported.” This means that, from a CPT perspective, the global surgical period extends from no more than one day before the day of the procedure to as long as is necessary for typical postoperative follow-up care to be completed. In essence, the postoperative period is open-ended.

Medicare’s view

As is common, Medicare’s rules differ slightly from that of CPT. Section 4821 of the Medicare Carriers Manual (available online at cms.hhs.gov/manuals/14_car/3b4820.asp#_1_2) provides a definition of Medicare’s global surgical package. Many other payers use this as a model. From a Medicare perspective, surgical procedures include the following services when furnished by the physician who performs the surgery:

• Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;

• Intraoperative services that are a usual and necessary part of a surgical procedure;

• All additional medical or surgical services required of the physician during the postoperative period of the surgery because of complications not requiring additional trips to the operating room;

• Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery;

• Postsurgical pain management;

• Certain supplies;

• Miscellaneous services (e.g., dressing changes; local incision care; removal of operative packs; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes).

Note a couple of distinctions between the Medicare and CPT package: First, unlike CPT, Medicare includes in the surgical package treatment of complications that do not require additional trips to the operating room. Second, unlike CPT, the postoperative part of Medicare’s global period is not open-ended. Medicare assigns postoperative global periods of 90 days to major surgeries and either zero or 10 days to minor surgeries and endoscopies. Any services beyond the Medicare postoperative global period, even if related to the procedure, are separately reportable. If you have any questions about the length of the postoperative global period assigned to a given code, you can find it in the Medicare Physician Fee Schedule database, available online at cms.hhs.gov/physicians/mpfsapp/step0.asp.

Decision for surgery

According to both CPT and Medicare, the decision for surgery is not part of the surgical package and should be separately coded using an E/M code. When the decision for surgery occurs more than one day before the day of the procedure, you can typically report the E/M code without any modifier, since neither the CPT nor the Medicare surgical package includes pre-operative services that occur more than one day before the date of the procedure.

If the decision for surgery occurs the day before the procedure, you should attach modifier -57, “Decision for surgery,” to the E/M code. This indicates that the E/M service resulted in the initial decision to perform the surgery and, therefore, should not be bundled in with the surgical procedure subsequently performed.

A more common scenario in family medicine involves making the decision to perform a procedure and then doing it during the same encounter. For example, a patient presents with a suspicious-looking skin lesion that the physician and patient agree should be removed at that visit. In this situation, if the E/M service that led to the decision to perform the procedure is significant and separately identifiable, the E/M service should be reported with modifier -25, “Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service,” in addition to the code for the procedure itself.

Unrelated services

Sometimes family physicians will see patients during the postoperative period for conditions unrelated to the surgical procedure. From both a CPT and Medicare perspective, such services are separately reportable. To signal that an E/M service performed during the postoperative period by the same physician is unrelated, attach modifier -24, “Unrelated E/M service by the same physician during a postoperative period.” To signal that the same physician performed another unrelated procedure or service during the postoperative period, attach modifier -79, “Unrelated procedure or service by the same physician during the postoperative period” to the appropriate code. Note that the modifiers are not needed if the physician is seeing patients during the global period after someone else has done the surgery.

Other issues to consider

Even though postoperative follow-up visits during the global surgical period are not separately payable, you may want to track them anyway. For example, you may want to track such visits to monitor your productivity or for purposes of doing practice-based research. One way to do this is to use code 99024, “Postoperative follow-up visit, included in global service.”

It’s also worth noting that the surgical package concept discussed above does not apply to all procedural services. For instance, maternity care services have their own global concept. Likewise, CPT has special rules for “starred” procedures; however, Medicare does not recognize those rules, and the starred procedure concept will be eliminated from CPT 2004.

The global surgery concept is widely applicable in family medicine. Understanding at least the basics of that concept can help bolster your bottom line.