Can you tell me where
to find what all is actually included in the surgical
package? (such as insertion/removal of k-wire,
dressings, etc...) My doctor has said to bill
the removal of k-wires (20680). The k-wire was
put in following a 4th toe Arthroplasty. They
were exposed and were removed in the office three
weeks after surgery. I know the CCI edit shows
it is included, but he said to use a -58 modifier.
We did this and it was paid. It is my
understanding that if he put the k-wire in with
intentions of removing it during the 90 day global
period it was included in surgery. Which is
correct? I have situations that come up
occasionally on what can or cannot be billed
separately from the surgical procedure during the
global period. I would like to be able to show
him this in writing to clear up the confusion. I
appreciate your help.
Services part one
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"
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
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
"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 inclusions.
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 common exclusions.
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
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
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
schedule allowance for the procedure. The
global period does not reset with the use of a
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,
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