Question

Surgical Package (Health Informatics Management) Thank you!

*What is a surgical procedure?

*Give the CPT definition of a Surgical package, describe what is included and how reimbursement works.

*Give the definition of Medicare Surgical Package.

*Analyze the information and describe the differences between the two definitions.

Answer 1

International Classification of Disease (ICD) 9-CM and case mix defines surgical procedures as all invasive therapies performed as inpatient surgery and a surgical operation or procedure which is performed with an overnight stay in an in-patient institution is termed as surgery. Surgery is also termed as a medical procedure involving an incision or cut with surgical instruments, performed to repair damage or tackle disease in a living body.

CPT Surgical Package Definition

The following services are included in a CPT surgical code when related to the surgery and when “furnished by the physician or another qualified healthcare professional who performs the surgery” as per the Surgery Guidelines section of the CPT manual.

1. Evaluation and Management (E/M) service(s) on the day before and/or day of surgery (including history and physical) related to the decision for surgery.

2. Forms of anesthesia like local infiltration, metacarpal/metatarsal/digital block or topical anesthesia

3. Any immediate postoperative care such as dictating operative notes, talking with the

family and other physicians or other qualified healthcare professionals

4. Writing orders

5. Assessment of the patient in the post-anesthesia recovery area

6. Regular postoperative follow-up care

The guidelines vaguely define how long the postoperative period lasts. But the inclusion of the only “typical” postoperative follow-up care defines the limit.

Surgery Guidelines section of the CPT manual clearly mentions the “Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported.”

Medicare Surgical Package

The definition of Medicare Surgical Package provided by the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers the Medicare and Medicaid programs differs in some important respects from the CP definition.

Medicare’s Global Package

Medicare’s global package concept for major surgery as outlined in Sections 4821 and 15501.1 of the Medicare Carriers Manual. It explains that all postoperative visits by the surgeon for the designated 90-day follow-up period are included in the fee for the surgery. All services that are not related to the surgery are separately billable.

All medically necessary re-hospitalizations to the operating room within the 90-day postoperative period are billable but the related surgeries do not change the follow-up period.

All unrelated surgeries start a new follow-up period.

Modifier -57 should be applied when you have to charge for the initial visit or consultation to determine the need for surgery, on the day of or the day before surgery.

No need to bill the preoperative visits on the day of or the day before the surgery separately as it is included in the fee for the surgery.

The surgery itself and all usual and necessary intra-operative services necessary to complete the surgery are payable in the surgery global fee.

All services related to management of complications are included in the surgery global fee and which may include the simple procedures performed at bedside or in a treatment room or physician’s office.

Common inclusions included in the GSP

• Pre-Operative Visits Within Pre-Operative Window
• Intra-Operative Services
• “Normal? Complications Following Surgery which may not require the return trip to operating
• Post-Operative Visits
• Post-Surgical Pain Management (multidisciplinary teams Surgeon vs. Anesthesiologist vs.

Other Physician)

• Miscellaneous Services like Incisional care, removal of tubes, drains,

casts, staples, lines, insertion of catheters, intravenous lines

General exclusions in the GSP

• Initial Consultation (“57” Modifier)
• Other Physicians – Unless the formal transfer of care.
• Visits and Treatment for Other Conditions or unrelated visits
• New or unrelated and Distinct Surgical Procedures (New Post-Op Period) ? “-
• 79” Modifier
• Any Complications Requiring Return to Operating Room (Include Cardiac
• Cath Lab)
• other -unrelated E/M Services
• Modifiers “-25” and “-24”
• Necessary Critical Care Services

Medicare guidelines for global surgery are available in the following publications

• Medicare Claims Processing Manual, Chapter 12, Section 40 (“Surgeons and

Global Surgery”)

• National Correct Coding Initiative Policy Manual for Medicare Services, Chapter

9 (“Radiology Services”)