When providing a procedure on the same day as an Evaluation and Management (E&M) Service, it’s important to understand payer guidelines, National Correct Coding Initiative (NCCI) and global period packages.
Per Chapter 1 General Correct Coding Policies, D. Evaluation and Management (E&M) Services, "Medicare Global Surgery rules define the rules for reporting evaluation and management (E&M) service with procedures covered by these rules."1
Procedures on the Medicare Physician Fee Schedule have a global period given to them:
- ZZZ or
The procedures that have a 000, 010, or 090 under limited circumstances may also have an E&M separately reportable within that global period.
Global period of 000 and 010 days is defined as a minor surgical procedure. Per NCCI, "[i]n general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedures. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25."
NCCI goes on to say, "[i]f a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is 'new' to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure."2 In addition, per NCCI, "[i]f a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57."3
For those procedures that have an 'XXX' (meaning global period does not apply), per NCCI, an E&M code may be applicable with a 25 modifier. That E&M service may be related to the same diagnosis that prompted the procedure. However, that procedure cannot include any work inherent in the procedure, supervision of others performing the 'XXX' procedure, or time for interpreting the result of the 'XXX' procedure because all procedures or procedures that have the XXX include pre-, intra-, and post procedural or interpreting the result of the XXX procedure. For work that is a required part of the procedure, it is not appropriate to report an E&M code.
The definition of XXX as the global period does not apply. For those procedures with YYY, "the global period is defined by the Carrier (A/B MAC processing practitioner service claims)." Procedures that are related to another procedure are identified with ZZZ and the global period is defined by the related procedure.
For major and minor surgical procedures, postoperative E&M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package as are E&M services related to complications of the surgery. Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed, unless related to a complication of surgery, may be reported separately on the same day as a surgical procedure with modifier 24 ("Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period").
According to Chapter 12 Section 40.2.8 of the Medicare Claims Processing Manual, entitled Significant Evaluation and Management on the Day of a Procedure, “Modifier ‘-25’ is used to facilitate billing of [E&M] services on the day of a procedure for which separate payment may be made. It is used to report a significant, separately identifiable [E&M] service by [the] same physician on the day of a procedure. The physician may need to indicate that on the day a procedure or service that is identified with a CPT code was performed, the patient’s condition required a significant, separately identifiable [E&M] service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed. This circumstance may be reported by adding the modifier ‘-25’ to the appropriate level of [E&M] service.”4
Mary Jo Gross, CPC, CANPC
Compliance – Anesthesia and Pain Management
McKesson Business Performance Services