Crystal-Clear Coding  

by Rick Horsman, DPM, and Scott Schroeder, DPM

The Question:
(Volume 111)

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.

Global Services   part one
by Rick Horsman, DPM

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 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 "-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    period.

         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.


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 



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