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Coding Corner: When is a Post-op Visit Not a ‘Post-op Visit’ | Kimberly Levinson, MD, MPH

Kimberly Levinson, MD, MPH

The post-operative period has variable length depending on the procedure (0, 10, or 90 days), and specific post-operative services are included in the global surgery payment. However, there are times when a patient may be seen during the post-operative period where the services rendered should not be considered part of the global and are billable separately.

 

Post-op services included in the global period

  • Miscellaneous services
    • Dressing changes
    • Local incisional care
    • Removal of operative packing or closing material (i.e. staple removal)
    • Insertion, irrigation, or removal of urinary catheters
    • Intravenous lines, nasogastric tubes, rectal tubes
    • Removal of tracheostomy tubes
    • Post-operative pain management
  • Complications from a surgery
    • Complications related to the surgical procedure that do NOT require a return to the operating room are included in the global package
      • A patient’s room, recovery room, ICU, or a minor treatment room are NOT considered an operating room and services provided in these locations can NOT be billed separately

Post-op services that should be billed separately and are NOT included in the global period

  • Services that are related to the condition but are for subsequent treatment
    • For gynecologic oncologists who administer chemotherapy, a visit in which treatment with chemotherapy is discussed should be billed separately
    • A modifier -79 should be used
  • E/M services that are not related to the diagnosis for which the surgery was performed
    • A modifier -24 should be used
  • A complication in which an additional operation where a return to the operating room is necessary
    • An operating room may include a cardiac cath suit, laser suite, or endoscopy suite, but not a patient’s room, recovery room, ICU, or minor treatment room
    • A modifier -78 should be used
  • A planned staged procedure or a more extensive procedure after a less extensive procedure
    • This may include a radical hysterectomy following conization
    • A modifier -58 should be used
  • Post-operative care (for an underlying condition or a complication) is performed by a non-surgeon
    • A modifier -55 should be used

More information can be found about the global period on the CMS website.

Excel files with the global period (0,10, or 90 days) can be downloaded from the CMS website.

Kimberly Levinson MD MPH is Director of Johns Hopkins Gynecologic Oncology at GBMC; Assistant Fellowship Director at Kelly Gynecologic Oncology Service; Assistant Residency Director at Department of Gynecology and Obstetrics and Assistant Professor at Johns Hopkins University School of Medicine.

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Our Coding Task Force members are happy to answer your coding questions, but are unable to review individual operative reports.

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SGO members and professional coders may seek coding advice and recommendations by submitting the form. Answers to incoming questions are provided by the members of the SGO Coding and Reimbursement Task Force and represent their opinion based upon the current and usual practices in the field. Every effort is made to ensure the accuracy of the information provided; however, the information neither replaces information in Medicare regulations, the CPT-4 code book, or the ICD-10 CM code book; nor does it constitute legal advice. Responses to questions are intended only as a guide and are not a substitute for specific accounting or legal opinions.

SGO expressly disclaims all responsibility and liability arising from use of, or reliance upon this information as a reference source, and assumes no responsibility or liability for any claims that may result directly or indirectly from use of this information, including, but not limited to, claims of Medicare or insurance fraud.

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