To 78 or 79: Coding for procedure services during the global period

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Manager, Lead Coding and Reimbursement Strategist, October 1, 2023

Academy coding staff address important coding topics each month in DermWorld Coding Consult. Read more Derm Coding Consult articles.

Reporting dermatology procedures and services during the global period requires careful consideration of the relevant coding rules and guidelines set forth by the CMS National Correct Coding Initiative (NCCI) and the American Medical Association’s Current Procedural Terminology (AMA/CPT^®) coding guidelines.

For accurate global surgery coding and compliance, Medicare established a national definition of a global surgical package to ensure that Medicare Administrative Contractors (MACs) make payments for the same services consistently across all jurisdictions. As coding rules and regulations continue to evolve, it is important to refer to the most current CMS regulations and CPT guidelines for accurate coding and billing. Proper documentation is crucial to support the medical necessity and appropriateness of any separately billable service(s) during the global period.

Sometimes, private payers may also implement payer-specific coding rules and regulations regarding billing for services during the global period. It is, therefore, essential to consistently update and review the AADA coding resources to ensure compliance with the latest coding rules and regulations that pertain to global period services.

To understand the global surgery package, here are some key points to keep in mind:

i. Global period

The global period refers to the timeframe during which all necessary follow-up care and services furnished by a dermatologist or non-physician clinician (NPC) before, during, and after the procedure are bundled into the payment for the initial procedure.

The global period duration varies depending upon the type of procedure and the CPT^® code reported. There are three main types of global surgical packages based on the number of post-operative days. Some services and/or procedures are contractor-priced codes, for which MACs determine the global period. Other global periods are determined by the MAC or are add-on codes and default to the global period for the primary code as indicated below.

The Medicare Physician Fee Schedule (MPFS) look-up tool — available at cms.gov — provides information on each procedure code, including the global surgery indicator.

ii. Global surgical package

Most medical and surgical procedures include all necessary services typically provided by the dermatologist or NPC before, during, and after a procedure.

When multiple procedures are performed at the same patient encounter, there is often overlap of the pre- and post-procedure work. As a result, payment methodologies for surgical procedures account for the overlap of the pre- and post-procedure work. The component elements of the pre- and post-procedure work for each procedure include component services of that procedure as a standard of medical/surgical practice. Learn more about what's included in the global surgical package.

Services included in the global surgery payment

Medicare and private payer payment for surgical procedures includes the pre-operative, intra-operative, and post-operative services routinely performed by the dermatologist/NPC or by members of the same group with the same specialty. Dermatologists and/or NPCs in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.

Additionally, the global surgical package includes all medical and surgical services required of the dermatologist/NPC during the post-operative period of the surgery to treat complications that do not require a return to the operating room.

• According to Medicare, an operating/procedure room is defined as any place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a laser suite. It does not include a patient’s room, minor treatment room, recovery room, or intensive care unit.

Medicare and private payers include the following services in the global surgery payment when provided in addition to the surgery:

• Pre-operative visits after the decision is made to operate;

  • For major procedures, this includes pre-operative visits the day before the day of surgery.

  • For minor procedures, this includes pre-operative visits on the day of surgery.

• Intra-operative services that are normally a usual and necessary part of a surgical procedure.

• All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room.

• Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery.

• Post-surgical pain management by the surgeon.

• Supplies, except for those identified as exclusions.

• Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, and removal of cutaneous sutures and staples.

Services not included in the global surgery payment

The following services are not included in the global surgical payment and may be billed and paid for separately:

• Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier 57 (Decision for Surgery).
Note:
The initial evaluation for minor surgical procedures is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery are included in the global package unless a significant, separately identifiable service is also performed. Modifier 25 is used to bill a separately identifiable evaluation and management (E/M) service by the same physician on the same day of the minor procedure.

• Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, or hospital record.

• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery.

• Treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery.

• Diagnostic tests and procedures, including diagnostic radiological procedures.

• Distinct surgical procedures that occur during the post-operative period and are not re-operations or treatment for complications.
  Note:
A new post-operative period begins with the subsequent procedure. This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure.

• Treatment for post-operative complications that require a return trip to the Operating Room (OR).

• If a less-extensive procedure fails, and a more-extensive procedure is required, the second procedure is payable separately.

• Immunosuppressive therapy for organ transplants.

iii. Post-operative services

During the global period, certain services may be separately billable if they are unrelated to the original procedure or are not part of the global surgical package. These services might include:

• E/M services for unrelated conditions or separate significant identifiable E/M services performed on the same day as the procedure — see modifier 25.

• Complications or exacerbations requiring additional treatment or surgery — see modifier 78.

• Services unrelated to the original procedure — see modifier 79.

• Unplanned procedures that were not part of the initial planned surgery — see modifier 58.

Appropriate use of modifier 78 and modifier 79

Modifier 78 and modifier 79 are both used to indicate that a subsequent procedure or service is performed during the post-operative period of the original procedure. However, they are used under different circumstances:

Modifier 78

When complications from a surgical procedure require a return to an operating room or procedure room for treatment, the service may or may not be billable, and may require appending an appropriate NCCI-associated modifier.

Modifier 78: Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following the initial procedure for a related procedure during the post-operative period is appended to the appropriate CPT^® code to indicate that the service is separate and distinct from the original procedure.

Key points for using modifier 78:

This modifier is reported when a patient returns to the operating or procedure room for a planned, unplanned, or related procedure that is a result of the initial procedure’s complications or unexpected issues. Other points to consider when reporting modifier 78 include:

• The subsequent procedure is related to the original procedure.

• It occurs during the post-operative period of the initial procedure (global period).

• It may be planned or unplanned but is necessary to address complications or issues resulting from the initial procedure.

• The procedure may be performed by the same dermatologist or NPC who performed the original procedure or by another surgeon from the same group or specialty.

It is important to note that the treatment of complications of primary surgical procedures is separately reportable with some limitations. The global surgical package for an operative procedure includes all intra-operative services that are normally a usual and necessary part of the procedure. Additionally, the global surgical package includes all medical and surgical services required of the dermatologist or NPC during the post-operative period of the surgery to treat complications that do not require a return to the operating room.

Thus, treatment complications of a primary surgical procedure is not separately reportable:

a. if it represents usual and necessary care in the operating room during the procedure; or

b. if it occurs post-operatively and does not require a return to the operating room.

What may qualify for reporting/billing with modifier 78?

• Treatment of complications that requires a return to an operating room (OR). For example, control of hemorrhage is a usual and necessary component of a surgical procedure in the operating room and is not separately reportable. Control of post-operative hemorrhage is also not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable with modifier 78.

• A patient on multiple blood thinners had Mohs micrographic surgery (MMS) with flap repair on Monday. The patient presents with expanding hematoma the next day, which is incised and drained (I&D) and packed. Modifier 78 is appended to the unplanned return to the procedure room during which the hematoma is incised, drained, and packed.

  • Additional procedure related to the first (not meeting the definition for modifier 58 use).

Modifier 79

When the dermatologist or NPC needs to indicate that the performance of a procedure or service during the post-operative period was unrelated to the original procedure, the service or procedure can be reported by appending modifier 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional to the subsequent/unrelated procedure or service, that is performed during the post-operative period of the initial procedure.

Key points for using modifier 79

This modifier is reported when a patient returns to the operating or procedure room for an unplanned procedure unrelated to the initial procedure. Other points to consider when reporting modifier 79 include:

• The subsequent procedure is unrelated to the original procedure.

• It occurs during the post-operative period of the initial procedure (global period).

• The procedure is medically necessary and distinct from the original procedure.

• It may be performed by the same physician or other qualified health care professional who performed the initial procedure, or it could be performed by a different physician or other qualified health care professional.

What may qualify for reporting/billing with modifier 79?

• A patient undergoes an excision of a biopsy-proven malignant lesion on the trunk and three days later returns for another excision of a biopsy-proven malignant lesion on the scalp. In this case, you would append modifier 79 to the code for the subsequent excision performed on the scalp to indicate that it is not related to the initial excision performed on the trunk. The two excised lesions, although both malignant, are located on two different anatomic sites, therefore unrelated.

• A patient underwent an excision of an atypical nevus on the back with repair. A week later, the patient came back with an inflamed cyst on the jaw, which required a procedure to drain it. Modifier 79 is appended to the cyst drainage procedure because it was not related to the previous surgery.

It’s important to use these modifiers accurately and only when appropriate. Proper documentation is essential to support the medical necessity and appropriateness of the subsequent procedure or service during the post-operative period. Additionally, be sure to follow the specific guidelines of the payer or insurance company to ensure proper reimbursement.

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