CODING Q & A

Solving Global Period Office Visit Coding Dilemmas

Information Provided By Riva Lee Asbell

One perennial recurring question is whether the physician can code for the office visit when complications arise in a global period. Most practices do not question routine global period management; however, when complications need treatment, queries arise.

GLOBAL PERIOD

For Medicare, the global period defines whether a surgical procedure is major or minor: 90 days for a major procedure and 0 to 10 days for a minor one. During this time, office visits related to the surgery can't be billed.

GLOBAL FEE

This is the concept by which Medicare pays for ophthalmic surgical procedures as listed on the Medicare Physician Fee Schedule Database. The global fee is divided into three portions for minor and major procedures respectively: (1) Ten percent is allotted for preoperative care for both; (2) Eighty percent (minor) or 70% (major) is allotted for intraoperative care; (3) Ten percent (minor) or 20% (major) percent is designated for postoperative care. When a complication or related problem occurs, such as endophthalmitis following pars plana vitrectomy, you cannot charge for the office visit.

Note: it is the office visit and medical treatment that are not billable, not treatment requiring surgical services. However, for surgical treatment to be paid by Medicare in the global period, the surgery must be performed in an operating room that meets this Medicare definition: “Treatment for postoperative complications requiring a return trip to the operating room. An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room, or an in tensive care unit (unless the patient's condition was so critical there would be insufficient time for transportation to an OR).”

PHYSICIANS IN A GROUP PRACTICE

Medicare states that when different physicians in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group. In a retina practice of five physicians, if the surgeon is on vacation and the patient returns for a complication, the office visit cannot be billed.

Q. If a patient comes in following an intravitreal injection with eye irritation, can the visit be billed?

A. Since the global period for intravitreal injection is 0 days, it can be billed; if there are no significant findings I would probably use 99212.

Q. If a PRP patient in the postop period develops recurrent or new vitreous hemorrhage, can the visit be coded?

A. No, because it usually is related to the original surgery and/or disease process.

Q. If a patient in the postoperative period of laser retinopexy develops new floaters, can the visit be coded? If they have a new tear, can the repeat retinopexy be coded?

A. If the patient develops new floaters, you cannot code the visit as above since part of the fee is dedicated to postoperative management. If a new tear develops related to the previous surgery or disease process, and the laser retinopexy is repeated, you can only bill the surgery by using modifier 78 that requires a return to the operating/procedure room as previously described.

Use caution whenever performing a related procedure in the office. An examining room used as a procedure room by having the laser wheeled in does not qualify as an OR or procedure room as required by the Medicare definition. This also applies to intravitreal injections performed after another procedure unless planned prospectively in which case modifier 58 would apply. RP

All CPT codes are copyrighted 2011 by the American Medical Association.