Coding Corner: When is a Post-op Visit Not a ‘Post-op Visit’ | 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.