Claims Review for Global Surgeries

40.3 - Claims Review for Global Surgeries (Rev. 11287; Issued:03-02-22; Effective:01-01-22; Implementation: 02-22-22) A. Relationship to Correct Coding Initiative (CCI) The CCI policy and computer edits allow A/B MACs (B) to detect instances of fragmented billing for certain intra-operative services and other services furnished on the same day as the surgery that are considered to be components of the surgical procedure and, therefore, included in the global surgical fee. When both correct coding and global surgery edits apply to the same claim, A/B MACs (B) first apply the correct coding edits, then, apply the global surgery edits to the correctly coded services. B. Prepayment Edits to Detect Separate Billing of Services Included in the Global Package In addition to the correct coding edits, A/B MACs (B) must be capable of detecting certain other services included in the payment for a major or minor surgery or for an endoscopy. On a prepayment basis, A/B MACs (B) identify the services that meet the following conditions: • Preoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure; or • Same day or postoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure or endoscopy; and - • Services that were furnished within the prescribed global period of the surgical procedure; • Services that are billed without modifier “-78,” “-79,” “-24,” “25,” or “-57” or are billed with modifier “-24” but without the required documentation; and • Services that are billed with the same provider or group number as the surgical procedure or endoscopy. Also, edit for any visits billed separately during the postoperative period without modifier “-24” by a physician who billed for the postoperative care only with modifier “-55.” A/B MACs (B) use the following evaluation and management codes in establishing edits for visits included in the global package. CPT codes 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99271, 99272, 99273, 99274, and 99275 have been transferred from the excluded category and are now included in the global surgery edits. Evaluation and Management Codes for A/B MAC (B) Edits 92012 92014 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99261 99262 99263 99271 99272 99273 99274 99275 99291 99292 99301 99302 99303 99311 99312 99313 99315 99316 99331 99332 99333 99347 99348 99349 99350 99374 99375 99377 99378 NOTE: In order for the services of CPT codes 99291 or 99292 to be paid during the preoperative or postoperative period, the critical care service must be unrelated to the procedure. In these situations, the physician must append the modifier -FT ((unrelated evaluation and management (E/M) visit on the same day as another E/M visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable). (Report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated.)) See section 30.6.12.7 of this chapter for further discussion of critical care visits unrelated to the procedure with a global surgical period. If a surgeon is admitting a patient to a nursing facility for a condition not related to the global surgical procedure, the physician should bill for the nursing facility admission and care with a “-24” modifier and appropriate documentation. If a surgeon is admitting a patient to a nursing facility and the patient’s admission to that facility relates to the global surgical procedure, the nursing facility admission and any services related to the global surgical procedure are included in the global surgery fee. C. Exclusions from Prepayment Edits A/B MACs (B) exclude the following services from the prepayment audit process and allow separate payment if all usual requirements are met: Services listed in §40.1.B; and Services billed with the modifier “-25,” “-57,” “-58,” “-78,” or “-79.” Exceptions See §§40.2.A.8, 40.2.A.9, and 40.4.A for instances where prepayment review is required for modifier “-25.” In addition, prepayment review is necessary for CPT codes 90935, 90937, 90945, and 90947 when a visit and modifier “-25” are billed with these services. Exclude the following codes from the prepayment edits required in §40.3.B. 92002 92004 99201 99202 99203 99204 99205 99281 99282 99283 99284 99285 99321 99322 99323 99341 99342 99343 99344 99345