Modifiers, Global Surgical Package and Bundled Services Explained

Q: “Can you explain a little bit about modifiers,
the global package and bundled services?” A: There’s a lot of information in one question. When we start to talk about these, a lot of
times you’re going to hear the phrases “global surgical package” and “bundled services.” When you hear those things, basically what’s
happening is the insurance company is wrapping all of the services related to a specific
procedure into the payment for that one CPT code. While there may be several CPT codes that
could be broken up to represent the different pieces, they say bill us the big one and we’re
going to bundle everything in there. Sometimes things are bundled and sometimes
they’re bundled into what we call a global surgical package. Now, there are different types of surgical
packages. We’ve got major surgical packages and your
minor surgical packages. Those all differ based on the number of global
service days. Think about the procedures that they’re
having performed. A patient has a major surgical procedure. Think about anything from restoring an open
fracture, lining the bone back up, closing that was created when the bone popped through
the skin, to removing organs. Maybe the patient had a hysterectomy. Those are major surgeries. They oftentimes take a long period of time
to heal well beyond ten days and they have what’s called the 90-day global package,
which means for 90 days everything that that surgeon does is bundled in to that major surgical
package. All those follow-up visits, anything that’s
related to the surgery gets bundled up. That’s a shortened version of what a major
surgical package is. I did include some links. I included the links to the Medicare website
that show you the difference between major and minor. We talked about major being major, 90 days;
minor is 10 days, it can actually be zero days or ten days. Again, those are going to be procedures that
don’t take quite as long to heal, and the difference between a zero and 10 days is going
to be what all is being performed. Things like scopes. Think about colonoscopy, those usually have
a zero-day global because you’re only going to see the patient that one day and everything
you do that one day is going to be included. That’s considered a zero day global. Maybe you have sutures and a laceration, that’s
probably going to have a 10-day global period because that skin has to heal and you’ve
got to see the patient back in 7-10 days to remove those sutures. That’s all considered part of that surgical
procedure of repairing the laceration. The other type of surgical package that we
have and it’s not really a surgical package, but it’s another type of package that we
see and that’s the obstetrical package. A lot of people forget that this is another
packaging or another bundling. When we talk about major surgery and minor
surgery, we were talking about a procedure that was being performed and all the services
associated with it were lumped in. Talk about the obstetrical package, we’re
talking about a patient who’s pregnant and all of the care related to the pregnancy is
lumped in to what we call their obstetric package. Billing for an obstetric package
is a little bit different and each carrier has different rules. The link that I gave you here is actually
a link to ACOG (The American Congress of Obstetricians and Gynecologists), a lot of the stuff on
their site is pay only. You have to be a member to get it and you
have to be a physician to get to it. This is one of the free articles that they
put out there. They actually talk about when that package
begins, and it begins when the confirmation of pregnancy is documented. It bundles all of these things together, and
you’re going to see if you look at the CPT codes specific to the OB package, that typically
that OB package includes 13 antepartum visits, anything before the baby is born. It includes labor and delivery, and it includes
the follow-up care with mom. You’re probably going to see her for a day
or two while she’s in the hospital before you discharge her and let her go home. Then you’re going to see her back six weeks
after delivery to make sure she’s healed OK. Babies acclimating to the household, mom doesn’t
have any major postpartum issues that we need to deal with. All of that. That’s another type of package that they’ve
bundled that payment together. Surgical packages were one piece, bundling
is another thing. Surgical package includes bundled services,
but sometimes bundling is simply saying this procedure is part of this bigger procedure. Maybe when I go in and let’s say I do a
partial colectomy, if you go in and do a partial colectomy you’re removing part of the colon. Depending on which part you remove, there
may be a specific part to say, “Oh, I did just the sigmoid colon,” or “I did just
the transverse colon.” But if you did multiple pieces, a larger code
that you can use in place of the one that says I did this piece and this piece. That’s holy cow bundle. Says you can’t bill them separately. Now, sometimes they bundle things together
that are usually performed together and if they’re performed separately or they’re
not interrelated to one another, that’s where your modifiers come in. Modifiers are used to unbundle packages. It’s to unbundle surgical packages, to unbundle
the obstetric package, and to unbundle bundled procedures. I do give you the link there to NCCI Edits
on the Medicare website. If you’re not familiar with NCCI, this is
the National Correct Coding Initiative. This is what Medicare uses as their basis
for determining which procedures are bundled with one another; which ones can be billed
together, which ones can’t be billed together and which ones can be billed together if we
use a modifier. This is actually a nifty little document that
takes you through how to use the database of NCCI Edits, what the different pieces mean,
because when you put in two codes together, you’re going to get them to get to show
up one right next to the other. They explained what a column 1 code is, what
a column 2 code is; and you’ve got little numbers next to it, a 0, a 1, a 9, and it
explains to you if it has a zero there, that means you can’t ever bill those two procedures
together. They’re mutually exclusive; it’s one or
the other. If it’s got a “1” it means “Oh, well,
sometimes they go together,” and you might need a modifier to unbundle that. That sort of thing. They give you, like I said here an example
of the difference. If you have a “0” you cannot put a modifier
on. It’s not allowed, you can’t unbundle them,
it’s not going to happen. A “1” means you can put a modifier on
it if it’s appropriate. The “9” means a modifier is not really
applicable, it doesn’t have anything to do with that, so they take you through all
of the different pieces. If you go back to the answer sheet, we’re
going to talk about which modifiers affect bundling in the packages. There are lots of different modifiers that
may unbundle certain services. The first two I talked about are modifiers
24 and 25; 24 and 25 are E/M modifiers. They can only go in your evaluation and management
code. These two cannot ever go on a surgical procedure. This go on the evaluation and management. Modifier-24 says, “Hey, the patient was
here but I saw him for something completely unrelated to the surgery they had done.” We see this a lot in family practice. Maybe we have a patient who is pregnant, and
she comes in for something unrelated to the pregnancy. Maybe she has an ankle sprain. It has nothing to do with the fact that she’s
pregnant. We’re not seeing her for the pregnancy,
that she sees her OB for the pregnancy. We’re seeing her follow-up on her ankle
sprain. Oftentimes that’s a modifier-24 and states
unrelated, totally separate. Modifier-25 is used for some of those minor
surgical procedures that it’s decided we’re going to do it today after we’ve already
seen them for E/M. They came in for an office visit we didn’t know we were going to need
to do a minor procedure. Minor procedure could be anything from a lesion
removal, a laceration repair; those types of things. Again, the documentation has to be clear that
it was separate, but a -25 says “Hey, it’s separate and we could pull that E/M out separately.” The last five modifiers are all surgical modifiers;
these would go on your procedure code. This usually fall in the 10,000 to 60,000
series of CPT. These modifiers, the first three 54, 55, and
56 are used to break up the surgical package. Maybe your physician has the surgeon but here
she’s only doing part of the care. Maybe somebody else did the preop and the
postop, they’re only doing the surgery itself. They bill that CPT code with a 54 on there,
so I just did the surgery. That’s all I need paid for, don’t pay
me for the preop and the postop. If they only did the postop they’re only
seeing the patient after surgery for all that followup you use a 55. If they only did the preop you use the 56. Now it’s important to say that these are
the coding rules. Every payor is a little bit different. For example, Medicare really doesn’t like
that preop modifier and doesn’t recognize it in a lot of situations, so you need to
be familiar with the carrier rules if you’re using these from a billing prospective. Modifiers 57 and 59 are two additional ones
that you see. 57 says that we made the decision for surgery
today. 57 is also an E/M modifier but then on the
E/M code to say that the service we provided today is separately reportable from the surgery
because we’re going to do surgery today or tomorrow, but we just figured out we needed
to do it, and decided to do it today, and the doctor has to be clear to say we made
that decision during today’s encounter. Modifier 59 says it’s a Distinct Procedural
Service. This is what unbundles two surgical procedures
from one another and this is one of the biggest abused modifiers. People think, “Oh, I get an NCCI Edit, it
says these two don’t go together and I have “1” that says I can put a modifier on
it.” Just because you can doesn’t mean you should. They have to be separate. There has to be something different to use
that 59. Oftentimes it’s a different surgical site,
maybe it was an arm and a leg, maybe it’s a different surgical session. We took him to surgery in the morning, we
took him to a different surgery in the afternoon, but there’s got to be some distinct service
there. There’s got to be a separate piece before
you blow those apart. Just to recap, global surgical packages could
be either a major surgery, a minor surgery, or an obstetric package and those bundled
together payment for the type of procedure the patient received. Bundling is not limited just to packages,
sometimes CPT codes, one CPT code is bundled into another because it’s a more extensive
CPT code, and modifiers are used to break apart those packages, or those bundled services,
so that’s a synopsis of those three different concepts.

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