November 21, 2007
Problems with Global Surgical Billing
Based on analysis of our claims data and information from other sources, we are seeing an increase in inappropriate billing during the global period of major surgeries. This seems to involve three scenarios:
- Hospitalists or non-physician practitioners (NPPs) are doing what appears to be routine post-operative care, and billing Medicare for the visits involved, while at the same time the operating surgeon is also billing for the entire global surgery fee.
- Anesthesiologists are billing for what appears to be routine post-operative pain management services, often after insertion of an epidural or other type catheter for administration of drugs, while the operating surgeon bills for the entire global fee.
- Post-operative patients in certain units, such as surgical intensive care units, are being seen by intensivists because of a hospital/facility “mandated” rule that all patients admitted to that unit will be seen by an intensivist, or other type specialist, depending on the nature of the unit.
All of these scenarios are examples of incorrect billing to the Medicare program.
The global payment for major surgeries includes a pre-operative evaluation component, an intra-operative service component, and a post-operative care component. The post-operative component includes the usual care for a patient after the particular procedure, as well as management of the usual post-operative pain, by whatever method. Complications, including all medical or surgical services by the surgeon, related to the procedure but not involving a return trip to the operating room, are also a part of the global services and not paid separately. Pain management by whatever method, unless it is so complex as to be outside the scope of the surgeon, is also a part of the global service, and not paid separately.
Treatment for the underlying condition, added courses of treatment, or valid medically necessary consultations by other specialists are not part of the global service, and may be charged separately, when appropriately requested by the surgeon and properly documented.
There may be occasions when more than one physician provides services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the postoperative care is split between two or more physicians where the physicians agree on the transfer of care. When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services.
Physicians who perform the surgery and furnish all of the usual pre-and postoperative work bill for the global package by entering the appropriate CPT code for the surgical procedure only. Billing is not allowed for visits or other services that are included in the global package. When different physicians/providers in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group. The physician who performs the surgery is shown as the performing physician.
In the case of physicians who are not in the same group, it may be appropriate to use the -54 and -55 modifiers to denote splitting of the care. The physician performing the pre-operative and intra-operative care would bill with the -54 modifier, and the physician rendering the post-operative management would bill with the -55 modifier. In this case, neither physician can bill for any other services related to the procedure rendered during their portion of the care.
Medicare does not pay for services mandated by a third party. Medicare does pay for reasonable, medically necessary services. If the operating surgeon admits the patient to an intensive care unit post-operatively and feels it is medically necessary to request a consultation from another specialist for proper management of the patient’s condition, that is valid and should be done with the usual written request and all appropriate documentation by both the requesting physician and the consulting physician.
The foregoing lists several incorrect billing practices, and illustrates some correct ways to deal with these situations. Continued incorrect billing as above could constitute abusive or fraudulent billing, and any monies paid incorrectly may be subject to recoupment from providers involved in the erroneous billing.
