Follow these rules to ensure proper reimbursement

Reimbursement for in-office surgical procedures varies depending on when, where, and what procedure is performed. Understanding these rules ensures cleaner claims and proper payment.

Global surgery policy

In 1992, Medicare instituted a global surgery policy, which allows a single payment for all necessary services normally furnished by the surgeon before, during, and after a surgical procedure. The policy describes services that are and are not included in the definition of “global surgery.” Different rules apply to minor surgery vs major surgery. While some major surgeries may be performed in-office, only the reimbursement considerations for minor surgeries are described here.

The global surgery rules dictate that surgical services are “package deals.” The Medicare-approved amount includes payment for the following services related to the surgery when furnished by the surgeon or a member of the surgeon’s group:

• Preoperative visits beginning day of surgery for a minor procedure
• Intraoperative services that are usual and necessary to the surgical procedure
• Additional medical or surgical services required by the surgeon during the postoperative period to treat a complication in the office
• Follow-up visits during the postoperative period that are related to recovery
• Most surgical supplies (with few exceptions).

Certain services are not included in the global surgical package for minor surgery (MCM HCFA Pub. 14-3, Transmittal No. 1545, 6/1/96). These services are paid separately:

• Services of other physicians unless a co-management arrangement has been established
• Visits unrelated to the diagnosis for which the surgery is performed, unless the visits are a result of complications
• Diagnostic tests and procedures 
• Clearly distinct surgical procedures that are not reoperations or treatment for complications (staged procedures)
• Treatment for complications that require an operating room.

Commercial payers often follow these national Medicare rules, as well.

Minor surgery examples

Minor surgeries are those surgical procedures with zero- (0-) or 10-day postoperative periods. Examples include: foreign body removal (65222), punctal occlusion with plug (68761), correction of trichiasis (67820), and chalazion excision (67800). Intravitreal injections (67028) and some laser procedures, including selective laser trabeculoplasty (65855), laser peripheral iridotomy (66761) and panretinal (scatter) laser photocoagulation (67228) are also considered minor surgeries.

Office visit rules

For minor surgery procedures, the exam performed on the same day as the procedure is usually considered incidental and not paid separately. An exception is made when the evaluation and management service is considered a “separately identifiable service.” For example, a patient presents today for punctal occlusion with plugs (68761). The office visit is incidental to the procedure and is not reimbursed separately. However, if the exam focused on a separate condition, separate reimbursement is made. Consider a patient who receives punctal plugs for dry eyes in conjunction with a previously scheduled glaucoma follow-up visit. Append modifier -25 and a diagnosis of glaucoma (H40.--) to the exam charge.

CMS does not require a separate diagnosis to use modifier -25. While uncommon, there are cases where the exam focused on the same condition as the minor surgery could be bilable. For example, a patient has a history of chalazia on both lower eyelids. During today’s exam, it is decided to continue antibiotics and warm compresses for the right eye and excise the chalazion on the left eye. The exam would be reimbursed as a separately identifiable service (on the fellow eye), although the diagnosis for the minor surgery would be the same.

Follow-up visits during the postoperative period are not usually reimbursed separately; payment is included in the global surgery fee. However, an exam for an unrelated condition may be reimbursed. Append modifier -24 to the exam code. The use of modifier -24 following minor surgery is not common since the global period is short (0 days or 10 days).

Injections and supplies

Most injections are considered minor procedures. To correctly bill injections, include the code for the medication injected. Injectable agents are described using HCPCS codes.

Payment for injectable drugs is frequently based on the amount injected. It is important to know the concentration of the drug to assign the correct code. Read the HCPCS definitions carefull,y and report the appropriate number of units per dose on the claim. 

While a HCPCS code exists to identify a sterile surgical tray (A4550), it is rarely separately reimbursed.

Payment for the supply of punctal plugs is included in the physician’s payment to insert the plugs (68761).

Operative reports

Do not presume operative reports are needed only for surgeries performed in a hospital or ASC. All surgical procedures require operative reports. In addition to the patient’s name and the date of surgery, the operative report should include:

• Preop and postop diagnoses
• Indications for surgery
• Description of the procedure
• Discharge instructions.

The operative report is part of the patient’s medical record — usually separate from the same-day’s office note. A record of the patient’s informed consent is also required. 

Modifiers

Numerous modifiers apply to surgical procedures. These modifiers are key to reimbursement; some affect the amount of reimbursement, while others simply facilitate a timely payment. The TABLE lists modifiers commonly used on claims for in-office surgery and their reimbursement implications. 

Table. Key modifiers to know for in-office surgery

Other payers

This abbreviated discussion emphasizes Medicare’s global surgery policy. Other third-party payers often follow these rules, but it’s important to inquire about their policies. OP

Mary Pat Johnson, COMT, CPC, COE, CPMA is a senior consultant with Corcoran Consulting Group. She may be reached at 800-399-6565 or via e-mail at MPJohnson@CorcoranCCG.com.