Special Presentations of Essential Information
Fundamentally, physicians perform one of three
clinical services: 1) cognitive services, 2) procedural services, or 3) a
combination of cognitive-procedural services, in varying degrees.
"Cognitive" services are those performed "with your mind, your
mouth, and your pen." These are billed as E/M services.
The contrary are "procedural" services performed primarily "with
your hands." These might involve surgery, injections, x-rays, cast
applications, physical therapy, etc.; essentially anything performed as a
"hands on" service.
In today's podiatric practice, some office visits involve only procedural
services while other office visits involve only cognitive services.
However, many office visits are made up of components of both.
Global services or a "global package" represent a bundling of specific
services or component procedures that are "included" in any given CPT
code. Primarily, when one thinks of global services or a global package,
though, it seems to a CPT surgical code. In essence, the principle of
global services is that there are certain fundamental and component elements to
any procedural service that are included within the designated value of that
specific procedural service.
So, what ARE the included elements of a procedural service? It depends
upon the carrier/payer. One should be aware that Medicare holds the
overall title to having the most stringent rules. For purposes of
discussion, we will devote our time to Medicare rules.
"Global services" under Medicare include (this is not an all-inclusive
listing): "usual and customary" postoperative global care (0, 10, or
90-days); supplies and dressings used within the office setting; any anesthesia
administered by the operating surgeon; intraoperative use of a C-arm or
fluoroscopy by the surgeon; preoperative evaluation "after the decision is
made to operate," removal of any fixation device intended to be removed
within the global period without a return to the operating room; post surgical
management of pain or wound complications without a return to the operating
room; in fact, management of any and perhaps all complications that do not
require a return to the operating room; application of the initial cast or
splint with 24 hours of a surgery; removal of any cast, splint, or
dressing by the doctor who applied it; just to name a few of the most common
Notably, the global service under Medicare does NOT include: E/M services or
procedures unrelated to the diagnosis of the original procedure; medically
necessary x-rays; medically necessary cast reapplications; casting supplies;
preoperative examination "to determine the need for surgery"; DME;
medically necessary supplies dispensed for patient self/at home use; management
of complications that DO require return to the operating room; unrelated
surgeries performed in another's global period; just to name a few of the most
For services provided within the global period, but which are unrelated to that
procedure, billing with modifiers would be as follows:
Unrelated E/M services are billed with a "-24" modifier.
Unrelated procedural services are billed with a "-79" modifier. This
has no effect on payment, but does begin a new global period.
For services provided within the global period, but which are related to the
original procedure, the billing is as follows:
NOTE: Related E/M services are never billable in a global period.
Staged or related procedural services are billed with a "-58"
modifier. The provider would be reimbursed
100% up to the maximum fee schedule allowance for the procedure. The new
procedure resets the global
Related procedural services performed in a global are billed with a
"-78" modifier. The "-78" modifier
requires a documented return to the operating room. While the professional
service is paid for the
procedure, the practice expense portion is not. This results in an
approximate 50% reduction in the fee
schedule allowance for the procedure. The global period does not reset
with the use of a "-78" modifier.
WHEN DOES THE GLOBAL PERIOD BEGIN?
Medicare has stated that the global period begins the day of a "minor
procedure". A minor procedure has been defined by Medicare to include
those procedural services with 0 or 10-global days. That includes most
diagnostic and/or therapeutic injections, debridement of ulcerations, wound
care, management of avulsions, matricectomies, etc.
Medicare has also stated that the global period begins the day before any
"major procedure" (90-day global). That includes virtually any
procedural service involving resection of bone. Notably, non-Medicare
payers may have entirely different rules.
Part Two of Dr. Horsman's "Global Services" will appear in the next
issue of FootZine