Global Surgery Modifiers

Global Surgery Modifiers

What is the "Global" period? Global period is known as global surgical package. CMS and AMA have the same definition per CPT guidelines, the following services are always included in addition to the operation per se:

• Local or tropical anesthesia
• Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure(including history and physical).
• immediate postoperative care
• writing orders
• evaluating the patient in the post anesthesia care unit
• typical post operative follow-up care

Services not included in Global Package:

• Initial consultation or evaluation by the surgeon to determine the need for surgery
• Services of other physicians unless a transfer of care has been arranged
• Visits unrelated to patient's surgical diagnosis
• Treatment for the underlying condition or an added course of treatment that is not part or normal recovery from surgery
• Diagnostic tests and  procedures
• Staged or clearly distinct surgical procedures during the post-op period
• Treatment for post-op complications requiring return to the OR
• A more extensive procedure when a less extensive procedure fails
• Supplies such as surgical trays, splints and casting materials when certain surgical services are performed in the physician's office
• Immunosuppressive therapy for organ transplants
• Critical care services unrelated to the surgery for a critically injured person
• Pre-op evaluations outside of the global surgical period

Without a modifier, the above mentioned services will not get paid!!!

Modifier - 26: Professional Component

Append to procedure code

Certain procedures are a combination of a physician component and a technical component. When physician component is reported separately, add - 26 to the CPT code to identify that the physician's component only is being billed.

Example: A 72 year old woman comes to the Emergency Room complaining of chest discomfort. The physician orders a complete 2D echocardiography using the hospital equipment. The physician provides the written interpretation.

Report: CPT Codes: 93307-26

Note:

• For use by physicians when utilizing equipment owned by a hospital/facility  
• Interpretations must be separate, distinct, written and signed
• Not all procedures have a professional/technical split!
• Refer to Medicare Fee Schedule to determine what procedures are eligible for this modifier
• Common services billed with -26: Radiology, Stress test, etc.

Modifier - 54: Surgical Care Only

Append to procedure code

• Physician service to the patient was only the intra-operative procedure. The physician is paid a portion of the global package. Another physician(s) will perform the pre-operative and post-operative care.
•  There should be an agreement for the transfer of care between physicians.
• Do not use with procedure cods having a zero day global period.
• Do not use -54 if physician is a covering physician (locum tenen) or part of the same group as the surgeon who performed the procedure.
• Modifier -54 should only be appended to the surgical procedure codes.
• When a physician other than the surgeon performs services that are considered part of the surgical package, the agreed-upon percentage fee splits should appear in Block 19 of the CMS 1500 claim form for both physicians.
• Procedure codes with modifier -54 will be paid a percentage of the allowable charge. The percentage paid is variable and based on the Medicare Physician Fee Schedule.

Example: A neurosurgeon travels to a rural location to perform a craniotomy for drainage of an intracranial abscess. He assessed the patient the day before surgery, and performed the procedure. Follow-up care was performed by a local surgeon.

The neurosurgeon would report 61321-54.

Modifier - 55: Post Operative Management Only

Append to surgical procedure code

• Modifier -55 is reported when one physician performed the post-operative management only; another physician performed the surgical procedure. Modifier -55 is appended to the surgical code. The physician is paid a portion of the global package.
• Modifier -55 should only be appended to the surgical procedure codes.
• Procedure codes with modifier -55 will be paid a percentage of the allowable amount. The percentage paid is variable and based on the Medicare Physician Fee Schedule.

Example: A patient from a Neighbor Island may have surgery on Oahu and receive postoperative care from an internist at home. Because the postoperative care is included in facility's payment for the surgical package, the internist should not bill for office visits. The surgeon and the internist should reach an agreement about sharing facility's payment for the surgery. The internist will then bill for postoperative care using the surgical procedure code and modifier code - 55.

Modifier -56: Pre Operative Management Only

Append to surgical procedure code

During the preoperative visit, the surgeon discusses the surgery to be performed, evaluates the patient's condition and ability to tolerate the planned surgery, prepares the admission documents, and has the patient sign the appropriate consent forms. These services are not customarily delegated to another physician.

In some instances, the patient may have an ongoing physical problem that could pose additional risk during surgery. In such a case, the surgeon may send the patient to a specialist or their internist for surgical clearance. When this occurs, the specialist or internist will bill for the appropriate consultation or office visit and use the patient's condition as the primary diagnosis.

Modifier -58: Staged or Related Procedure by the Same Physician during the                                                 Postoperative Period

Append to surgical procedure code

• The purpose of this modifier is to report the performance of a procedure or service during the postoperative period for one of the following circumstances:

• planned or Staged.
• more extensive than the original procedure.
• therapy following a surgical procedure.

• This modifier is used to report a staged or related procedure by the same physician during the postoperative period of the first procedure.
• Modifier -58 is used only during the global surgical period for the original procedure.

Note:

• Modifier -58 should not be reported when treatment of a problem requires return to the operating room.
• Modifier -58 should not be used for staged procedures when the code description indicates "one or more visits or one or more sessions."
• Without the modifier, the third-party payer could reject the claim because the surgery occurred during the post-op period.

Example: 32 year old woman with breast cancer undergoes a mastectomy one week ago. Today, she is scheduled to have breast implants placed.

Report: 19342-58

Modifier -76: Repeat Procedure by the Same Physician; use when it is necessary to report repeat procedures performed on the same day.

Append to procedure codes that cannot be quantity billed.

Modifier -76 is used to report the service when the same procedure is performed by the same physician, on the same patient either the same day of the previous procedure or doing the global period.  The modifier tells the payer that this is not a duplicate bill, but that the same procedure was performed twice.  It requires the use of the same procedure code.   The modifier may be used on procedures or diagnostic tests.

Appropriate Usage

• On procedure codes that cannot be quantity billed.
• Report each service on a separate line, using a quantity of one and append 76 to the subsequent procedures.
• The same physician performs the services.

Inappropriate Usage

• Appending to a surgical procedure code.
• Appending to each line of service.
• Repeat services due to equipment or other technical failure.
• For services repeated for quality control purposes.

Additional Information

• Medicare considers two physicians, in the same group with the same speciality performing services on the same day as the same physician.
• For all procedure codes that cannot be quantity billed, always use a quantity of "1".
• To avoid denials, bill all services performed on one day on the same claim
• For repeat clinical diagnostic laboratory tests, use modifier 91 if the service cannot be quantity billed.
• Indicate in the electronic narrative record or Box 19 of the CMS 1500 claim form, the total number of services performed that day.

Example: A physician orders an EKG 93000 (routine EKG with at least 12 leads; with interpretation and report). It is performed at 8:00 a.m. It is repeated at 1:00 p.m. Later, the patient's condition requires a third EKG 93000, the same physician orders it and it is repeated at 10:00 p.m.

This is billed as 93000, one unit (first line) and 93000-76, two units (next line).

Modifier -77: Repeat procedure or service by another physician or other qualified health care professional

Appropriate usage

• Append to the professional component of an X-Ray or EKG procedure when a different physician repeated the reading as the physician performing the initial interpretation believes another physician's expertise is needed.
• Append to the professional component of an X-Ray or EKG procedure when the patient has two or more tests and more than one physician provides the interpretation and report.
• Append when billing for multiple services on a single day and the service cannot be quantity billed.

Inappropriate usage

• Billing for multiple services considered bundled.
• Billing on an Evaluation and Management Code.

Example: Procedure 44366 (small intestinal endoscopy beyond second portion of duodenum, not including ileum) is performed on a patient twice in a day. The only difference is that the second procedure is ordered by a different physician.

This is billed as 44366, one unit (first line) and 44366-77, one unit (next line).

Modifier -78: Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postoperative period.

Appropriate usage

• To identify a related procedure (that has a 000, 010, 090, YYY, or ZZZ global surgery indicator on the Medicare Fee Schedule Database [MFSDB]) requiring a return trip to the operating room* (OR) on the same day as or within the postoperative period of a major or minor surgery.
• To treat the patient for complications resulting from the original surgery (Note: The CPT definition for the modifier does not limit its use to treatment for complications).
• When the procedure code used to describe a service for treatment of complications is the same as the procedure code used in the original procedure, modifier 78 is still the correct modifier to use.

Inappropriate usage

• On any procedure code that does not have a global surgery indicator of 000, 010, 090, YYY or ZZZ on the MFSDB.
• When the surgery is unrelated to the original procedure.
• On procedures performed in any place other than the OR.

Facts

• Modifier -78 allows for the intra-operative percentage only of major or minor procedures (010 or 090 global surgery indicators).
• A new postoperative period does not begin when using modifier 78.
• Medicare allows codes with a global surgery indicator of XXX in the MPFSDB separately without modifier 78.
• Medicare allows the lower of either 100% of the fee schedule or the billed amount for codes with a global surgery indicator of 000.
• The patient must be returned to the O.R. or endoscopy suite to qualify for the 78 modifier. Unlike modifiers 58 and 79, 78 may not be performed anywhere but in the O.R. or the endoscopy suite.

Example: The physician performed a repair of an abdominal aneurysm. Later, the patient has internal bleeding and needs to return to the operating room to have suturing of a bleeder.

Report: 35082 and 35840-78.

Thanks for reading,

Pankaj Kumar