One of the biggest conundrums in Ophthalmology concerns global surgery and what this all means when providing related procedures, bilateral procedures and incidental care after a procedure.
First, let’s review what “surgery” involves from a coding perspective. From a Medicare standpoint global surgery (which has been around since 1992) includes basic pre-operative care on the day of surgery, intra-operative care and post-operative services in a single payment. Let’s walk through a couple of patient care examples:
Tammy comes in with a foreign body of the right eye that you identify as imbedded and remove with the appropriate instrument. Prior to the removal you did a bilateral eye exam, a general history and identified the patient in general good health, no chronic vision or eye issue, reviewed medication and chronic conditions. Proceeded to remove the foreign body, educated patient and provided. Post procedure care reviewed, perhaps eye drops, avoidance of contacts, etc.
In this case because the procedure, CPT code 65205 has no global time frame (0) the E/M visit would be coded with modifier -25 and the procedure with the RT and LT (eye location). Remember that modifier -25 is defined as a “separately identifiable” E/M service with a procedure.
Tammy returns in 3 days with a red irritated eye and pain, you assess and review, make recommendations for treatment. This visit can be coded as the 9921x without any modifier because there is no global time frame for the procedure.
Joe comes in for a laceration above the left eye. You assess the vision, discuss the nature of the injury, review PMH as well as prior vision issues. Laceration occurred when baseball contacted glasses and the cut, above the eye is deep with some debris requires a layered closure. The wound is cleaned, lidocaine used to the affected area and defect closed after removal of foreign material. Length of the wound 3.2 cm. The debris appeared to be grass and maybe a little gravel. This would be coded with the 9920x (new patient) and the 12052. New patient services do not require a -25 on the same day as a procedure. The 12052 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm has a 10-day global time frame. For the next 10 days any care related to this laceration repair would not be covered.
Joe comes back in 3 days for a wound check and is going fine – this would not be coded and billed. Joe comes back in about a week (under 10 days) for routine vision care in 9 days for new glasses and to talk about contact lenses. This vision service would be coded as an established patient (either 92012 or 92014 based on the extent of history, exam and vision issues). This code may or may not (insurance dependent) require you to use modifier -24, unrelated E/M during a global procedure time, dependent on the insurance plan. Remember that the prior diagnosis for vision care Z01.01 and the specific condition requiring eyewear.
You have been seeing Mildred for over 10 years for her routine vision care (wears corrective lenses) and diabetic eye exam without complications. Now her bilateral cataracts are at the stage the surgery is an appropriate treatment option. You complete the comprehensive eye exam, identified imaging and measurements, as Millie has decided she will pay for the special lenses to never have to wear glasses again. You proceed to schedule both procedures, 3 weeks apart.
All of the options for cataract surgery have a 90-day global time frame, which means that once you have determined the appropriate procedure any related E/M services are considered part of the procedure umbrella. The initial assessment for procedure determination and planning can be coded and no modifier is required (unless you perform the procedure the same day). Your assessment the day of the procedure for the ASC or OR is part of the global package as is the operative care and follow up for the next 90 days for anything related to the procedure.
You perform Millie’s cataract procedure on May 1st on the left eye and all goes well, and you see her back 2-3 days post procedure. This is a no charge visit as part of the global service. Millie returns at 2 weeks to confirm and plan for the cataract procedure for the right eye. She has already been through testing, history and exam at the initial assessment, so this visit is not billable as it is an anticipated visit. If there were a change in plan, a new issue or complication for the right eye this may be code-able with modifier -24 (unrelated E/M visit during a global time period) if the issues were not addressed at the initial visit.
Ron had his first cataract surgery in January on the left eye. He had planned to have the second one in 6-7 weeks after the first. He had all the testing, assessment and was ready to go, but he got COVD, and his second cataract was pushed back 3 ½ months. Before this second procedure you brought Ron back into the office to make sure he was an acceptable risk for the second eye and that nothing had changed. This visit is code-able, and no modifier is needed.
Let’s look at the case of Jack. He also had cataracts identified at a visit in March, but only the right eye was planned for surgical intervention as the left eye was not yet at the stage for Medicare to pay for this procedure. He has cataract surgery on the right eye but then 2 months later he comes in with increased blurred vision on the left, and you now determine he meets criteria for cataract surgery as his cataract rapidly progressed. Your documentation identifies this change in May from March, the additional work up with imaging and planning are provided. This visit would support the 9921x-24 as an unrelated E/M visit during the global time frame because the surgery was not anticipated or planned for back in March. For you to code this care as unrelated one must have clear documentation at the initial visit as well as the one still under the global umbrella.
Unrelated procedures or conditions would be code-able during a global time frame based on good documentation and diagnoses coding.
Mike comes in for an urgent retinal procedure on the left eye (which has 90 days) with the assessment today and work up, and he proceeds immediately (today) to the OR for care. The E/M service is coded with the 992xx-57 (decision for procedure) and the specific retina procedure code (RT or LT).
Mike returns for post procedure care that is included in the global time frame. At week 6 he returns and has vision issues in the right eye – this is code-able as it is unrelated to the surgical care on the left eye.
As we look at when E/M services can be coded with a surgical procedure this is allowed when the procedure is on the same day as the assessment. Modifier -57 would be appended for a major procedure and modifier -25 for a minor procedure (some insurance programs allow both modifiers to be appended). Modifier -24 is only used when the care provided during the global post time period is for a clearly documented unrelated visit.
Ohio Ophthalmological Society (OOS) member practices may receive free assistance for problems or questions related to coding, documentation, denials, and other payer related issues. Go here for the online help form.