Monday, February 17, 2020

Post operative period billing guidelines - Modifier usage


POST-OPERATIVE PERIOD BILLING

Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period

Two CPT modifiers are used to simplify billing for visits and other procedures that are furnished during the post-operative period of a surgical procedure, but not included in the payment for surgical procedure. These modifiers are:

Modifier “-79” (Unrelated procedure or service by the same physician during a post-operative period).

The physician may need to indicate that a procedure or service furnished during a post-operative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.

Modifier “-24” (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure. Special Reporting for Certain Practitioners for CPT code 99024 Practitioners are required to report post-operative E/M visits using CPT code 99024 if they:

• Practice in one of the following nine states: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, or Rhode Island; and

• Practice in a group of ten or more practitioners;

• Practitioners who only practice in practices with fewer than 10 practitioners are exempted from required reporting, but are encouraged to report if feasible and,

• Provide global services under one of the required procedure codes. The required procedure codes are those that are furnished by more than 100 practitioners and either are nationally furnished more than 10,000 times annually or have more than $10 million in annual allowed charges.

The term “practitioner” is used to refer to both physicians and nonphysician practitioners (NPPs) who are permitted to bill Medicare under the PFS for services furnished to Medicare beneficiaries (see 81 FR 80172). This  reporting is required for post-operative visits during the global period for procedures with dates of service on or after July 1, 2017. For more information, see Claims-Based Reporting Requirements for Post-Operative Visits. Codes for Which Reporting on Post-Operative Visits is Required As of January 1, 2018, there are some changes made to the list of codes for which reporting is required.

These changes are made necessary by changes in the coding system.

The following CPT codes no longer need to be reported: CPT codes 15732, 34802, and 34825 are deleted. Reporting is not required after December 31, 2017.


CPT codes 30140, 36470, and 36471 have a 0-day global period so reporting is not needed.

The Codes for Required Global Surgery Reporting (CY 2018) [ZIP, 20KB] shows the codes for which reporting is required on or after January 1, 2018.

Return to the OR for a Related Procedure during the Post-Operative Period

When treatment for complications requires a return trip to the operating room, physicians bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, the physician should use the unspecified procedure code in the correct series, which is, 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated.

In addition to the CPT code, physicians report modifier “-78” (Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the post-operative period).  The physician may also need to indicate that another procedure was performed during the post-operative period  of the initial procedure. When this subsequent procedure is related to the first procedure, and requires the use of the operating room, this circumstance may be reported by adding the modifier “-78” to the related procedure.

NOTE: The CPT definition for modifier “-78” does not limit its use to treatment for complications.

Staged or Related Procedure or Service by the Same Physician During the Post-operative Period Modifier “-58” (Staged or related procedure or service by the same physician during the post-operative period) was established to facilitate billing of staged or related surgical procedures done during the post-operative period of the first procedure. Modifier “-58” indicates that the performance of a procedure or service during the post-operative period was:
• Planned prospectively or at the time of the original procedure
• More extensive than the original procedure
• For therapy following a diagnostic surgical procedure Modifier “-58” may be reported with the staged procedure’s CPT. A new post-operative period begins when the next procedure in the series is billed.

Critical Care

Critical care services furnished during a global surgical period for a seriously injured or burned patient are not considered related to a surgical procedure and may be paid separately under the following circumstances. Pre-operative and post-operative critical care may be paid in addition to a global fee if:
• The patient is critically ill and requires the constant attendance of the physician; and
• The critical care is above and beyond, and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed.


Special Reporting for Certain Practitioners for CPT code 99024

Practitioners are required to report post-operative E/M visits using CPT code 99024 if they:

• Practice in one of the following nine states: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, or Rhode Island; and
• Practice in a group of ten or more practitioners;
• Practitioners who only practice in practices with fewer than 10 practitioners are exempted from required reporting, but are encouraged to report if feasible and,
• Provide global services under one of the required procedure codes. The required procedure codes are those that are furnished by more than 100 practitioners and either are nationally furnished more than 10,000 times annually or have more than $10 million in annual allowed charges.

The term “practitioner” is used to refer to both physicians and nonphysician practitioners (NPPs) who are permitted to bill Medicare under the PFS for services furnished to Medicare beneficiaries (see 81 FR 80172). This reporting is required for post-operative visits during the global period for procedures with dates of service on or after July 1, 2017

Return to the OR for a Related Procedure during the Post-Operative Period

When treatment for complications requires a return trip to the operating room, physicians bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, the physician should use the unspecified procedure code in the correct series, which is, 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated.

In addition to the CPT code, physicians report modifier “-78” (Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the post-operative period). The physician may also need to indicate that another procedure was performed during the post-operative period of the initial procedure. When this subsequent procedure is related to the first procedure, and requires the use of the operating room, this circumstance may be reported by adding the modifier “-78” to the related procedure.

NOTE: The CPT definition for modifier “-78” does not limit its use to treatment for complications.

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