Last updated on 9/5/24 | First published on 9/10/19 | Literature review current through Oct. 2024
[cite]
Authors:
Tiffany Hamm BSN, RN, CWS, ACHRN, UHMSADS,
Jeff Mize RRT, CHT, UHMSADS,
Eugene Worth MD, M.Ed., FABA, ABPM/UHM,
Elaine Horibe Song MD, PhD, MBA,
more...
Coauthor(s)
Elaine Horibe Song, MD, PhD, MBACo-Founder and Editor, Wound Reference, Inc;
Professor (Affiliate), Division of Plastic Surgery, Federal University of Sao Paulo;
Chair, Association for the Advancement of Wound Care;
Google Scholar Profile
Disclosures: Nothing to disclose
Jeff Mize, RRT, CHT, UHMSADS
Disclosures: Nothing to disclose
Tiffany Hamm, BSN, RN, CWS, ACHRN, UHMSADS
Chief Nursing Officer, Wound Reference, IncDisclosures: Nothing to disclose
Eugene Worth, MD, M.Ed., FABA, ABPM/UHM
Disclosures: Nothing to disclose
Editors
INTRODUCTION
Background
Wound physicians and qualified healthcare professionals (QHP) must be aware of the surgical global packaging rules as they relate to the transfer of care from one provider to another. Documentation and proper billing methods are essential to meet CMS compliance standards and to ensure the rules are followed. Failure to do so could make the wound care provider a target for audit and denials. In a report, the Office of the Inspector General (OIG) found that providers didn’t always comply with federal requirements when they bill for surgical services, including missing co-surgery and assistant-at-surgery modifiers. OIG estimated that Medicare made $4.9 million in improper payments for physician surgical services during their audit period over 2 years. [1]
NOTE: The Medicare global surgical package does not apply to hospital-based outpatient departments (HOPDs) that are paid under the Medicare ambulatory payment classification system (APC). The global surgical package only applies to the physicians/QHP who are paid under the Medicare physician fee schedule.[2]
Definition:
The global surgical package, also called global surgery, includes all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for the surgical procedure includes the pre-operative, intra-operative and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians/QHPs in the same group practice who are in the same specialty must bill and be paid as though they were a single physician/QHP.[3]
There are three types of global surgical packages based on the number of post-operative days included in the package.
- Zero-day postoperative period (endoscopies and minor procedures)
- 10-day postoperative period (minor procedures)
- 90-day postoperative period (major procedures)
To find out which option applies to each procedure, see section 'Identifying the number of postoperative days included in each procedure' below.
Relevance:
- A common scenario occurring in wound clinics is the request for follow-up wound services by surgeons during the post-operative global period. Wound clinic physicians/QHPs might be seeing these patients with the intention of offloading some of the work for the surgeon or believing that they are increasing volume in their own clinics. However, if transfer of care is not properly documented and claims are not adjusted to reflect transfer of care, the program can become a target for audit and denials.
- More than one physician may furnish services included in the global surgical package. For instance, the physician who performs the surgical procedure may not furnish follow-up care and instead delegate it to another physician. In this case, payment for the post-operative, post-discharge care may be shared among two or more physicians/QHPs where the physicians/QHPs agree on the transfer of care.[3]
PROTOCOL
Global Surgical Transfer of Care
A simplified protocol for global surgical transfer of care is provided below [2][3]:
| Important tasks | When | Key Points (how to execute the task) | Reason (why execute the task) |
| Agree with the transfer of care and document it | Agree prior to transfer of care, document before and after transfer of care | - For every patient, the surgeon and the physician furnishing the post-operative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. See 'Post-operative Co-management Transfer of Care Form'
- If transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.
- Where physicians/QHPs agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier as described[3]
- To ensure communication gaps are minimized during transfer of care, clinicians may opt to utilize tools/ checklists such as the "Provider to Provider Wound Communications Custom Form"
| Per CMS guidelines, to ensure documentation supports the services provided in the event of a post-payment review by the payor |
| Provide post-operative clinical services | After transfer of care, within post-operative days specified by the type of global surgical package (0, 10 or 90 days) | The following services are included in the global surgery payment when furnished by the physician who furnishes the surgery [3]
- All additional medical or surgical services required by the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room;
- Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery;
- Post-surgical pain management by the surgeon;
- Supplies, except for those identified as exclusions; and
- Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.[3]
| The CMS global surgery packages apply to procedure codes with global surgery indicators of 000, 010, 090. Codes with 000 have a zero-day postoperative period. Codes with 010 have a 10-day postoperative period and codes with 090 have a 90-day postoperative period.[3] |
Use appropriate modifier for billed services
| When billing after services have been provided, if physicians have agreed and documented transfer of care[3]
| - For surgical care only: the surgeon should add modifier "-54" to his/her CPT code
- For post-operative management only: the physician/ QHP providing postoperative care should add modifier “-55” to the same CPT code at the first post-operative visit
- See rules for global surgery services billed with modifiers “-54” or “-55" in Table 1 below [3]
| The CMS designated modifiers appended the claim by the billing department will ensure correct and timely payment |
Identifying the number of postoperative days included in each procedure
To find out which option applies to each procedure:
- Go to the Medicare Physician Fee Schedule Search Tool
- Enter search criteria
- Select the Year
- Under "Type of Information", select "Payment Policy Indicators"
- Enter HCPCS code of the procedure
- Under "Modifier", select "All"
- See search results
- See value in the column titled "Global"
- XXX means that global surgery concept is not applicable to this code
Rules for global surgery services billed with modifiers “-54” or “-55”
Table 1. Rules for global surgery services billed with modifiers “-54” or “-55"
Applicable to both modifiers “-54” or “-55"
- The same CPT code must be billed.
- The same date of service and surgical procedure code should be reported on the bill for surgical care only and post-operative care only.
- The date of service is the date the surgical procedure was furnished.
Applicable to modifier "-54":
- Indicates that the surgeon is relinquishing all or part of the post-operative care to another (or a different) physician
- Modifier “-54” does not apply to assistant at surgery services
- Modifier “-54” does not apply to an ASC’s facility fees
Applicable to modifier "-55": - The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55”
- Documentation must include the following:
- Use modifier “-55” with the CPT code for global periods of 10 or 90 days.
- Report the date of surgery as the date of service and indicate the date care was relinquished or assumed.
- Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.
- The receiving physician must provide at least one service before billing for any part of the post-operative care.[3]
|
CLOSINGIt is important that wound care physicians/QHPs develop a relationship with surgeons who transfer care to their departments during the global surgical period. Developing a methodical approach to accepting these surgical patients (with accurate and complete documentation) will benefit both parties. Cooperation between the two parties will ensure excellence in patient care, billing compliance, and appropriate reimbursement.
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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.
