September 28, 2016

Pay Careful Attention Regarding Evaluation and Management Services and the Global Surgery Period


From international law firm Arnold & Porter LLP comes a timely column that provides views on current regulatory and legislative topics that weigh on the minds of today's physicians and health care executives.

The global surgical payment, which applies to many surgical procedures, such as cataract surgery, includes all necessary services normally furnished by a surgeon before, during and after a procedure. The global surgery payment applies in any setting, including inpatient hospital, outpatient hospital, ambulatory surgical center and physician office. Although the 2015 Physician Fee Schedule Final Rule would have eliminated the 10-day and 90-day surgical payment periods — converting both to a "0-day" surgical period — the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which was signed into law by President Obama on April 16, 2015, undercut those plans. Instead, MACRA now requires CMS to collect surgical care data and to re-evaluate surgical payment in the coming years.

While CMS considers the future of payment for surgical procedures, including what individualized billing may be appropriate, the continued relevance of the 10-day and 90-day global periods still requires significant caution on the part of physicians when billing for separate services on the day of surgery or in the relevant global period that follows. This is especially true with regard to evaluation and management (E/M) codes. Indeed, one of the goals of CMS in seeking to convert to 0-day surgical periods was to "[e]liminate disparities between the payment for E/M services in global periods and those furnished individually." The Department of Health and Human Services Office of Inspector General (OIG), moreover, continues to scrutinize E/M billing in relation to global surgery claims. In particular, an OIG report from September 2015 indicates that "providers that submit an unusually high percentage of claims with modifiers 24 or 25 may be using the modifiers to inappropriately receive payment for these services."

Inadequate documentation or a high rate of billing modifiers -24 and -25 may therefore subject a physician or practice to government scrutiny. It is important to pay careful attention to the following Medicare guidelines for billing these modifiers during the global surgery period:

  • Modifier -24 reports an unrelated E/M service by same physician during a postoperative period. Services submitted with the "24" modifier must be sufficiently documented — eg, through appropriate diagnosis code — to establish that the visit was unrelated to the surgery.
  • Modifier -25 is used to facilitate billing of E/M services on the day of a procedure for which separate payment may be made. It is used to report a significant, separately identifiable E/M service by same physician on the day of a procedure. The physician may need to indicate that the patient's condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed."

Global surgical payment periods may eventually be a thing of the past, but careful billing and coding while these still exist is of paramount importance. In addition to proper coding for E/M services during the global period, physicians and practices also should ensure clear and thorough medical documentation when billing modifiers -24 and -25.

Allison W. Shuren, MSN, JD, a partner at Arnold & Porter LLP, can be reached at

Matthew T. Fornataro, JD, an associate at Arnold & Porter LLP, can be reached at


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