February 14, 2019
8 min read
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Place of service affects postoperative care billing and payment

Refer to the CMS Global Surgery Booklet for billing guidance on re-operations and postoperative treatments.

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Question: You are a fellowship-trained glaucoma surgeon who provides care to advanced glaucoma patients with refractory and complex disease. Following glaucoma surgery, many patients require additional care during the postoperative period. This additional care sometimes includes another procedure in order to control the patient’s IOP. Some procedures can be performed in the lane at the slit lamp; some are performed in a minor procedure room; some are performed in a laser suite; and some are performed in the operating room of an ASC or hospital outpatient department. All of these procedures are related to the initial glaucoma surgery in some way. Broadly speaking, postoperative care is not separately billed; however, there are exceptions to this rule that permit separate reimbursement from Medicare and other third-party payers. Your billing staff wants clarification about the impact of the place of service on billing for procedures that take place within the global period of a major glaucoma procedure.

Discussion

Your search for clarification of this issue identifies a comprehensive resource that is available on the CMS website: CMS’ Medicare Learning Network — Global Surgery Booklet. This resource defines services that are and are not included in the global surgery payment. An example of an excluded service includes “[c]learly distinct surgical procedures that occur during the postoperative period which are not re-operations or treatment for complications.” Additionally, the booklet identifies other criteria for services that are not part of the global surgery package, including:

  • Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery.
  • If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.
  • Treatment for postoperative complications requiring a return trip to the operating room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR). (Emphasis added.)

The place of service where the treatment of a complication occurs is important because re-operations or treatment for complications are not separately reimbursed unless it requires a return to an operating room. You and your billing staff engage in lively discussion of these rules using recent clinical vignettes for the sake of clarification.

John S. McInnes
John S. McInnes

Case 1

Following a combined cataract extraction and trabeculectomy for uncontrolled primary open-angle glaucoma (POAG), the patient returns on postoperative day 1 with an IOP of 40 mm Hg in the operated eye and normal pressure in the unoperated eye. You lower the pressure in the operated eye by performing a paracentesis at the slit lamp in your office. Can you bill for this procedure, and if so, how?

Answer

No, you cannot bill separately for this procedure. Trabeculectomy is a major surgery with a 90-day global period. The paracentesis was performed to manage the postoperative complication of elevated IOP. The procedure was performed in the office at the slit lamp and did not require a return trip to the operating room. Therefore, it is included within the global payment for the trabeculectomy and is not separately billable.

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Case 2

Kevin J. Corcoran
Kevin J. Corcoran

Following a combined cataract extraction and trabeculectomy for uncontrolled POAG, the patient initially has an uneventful postoperative course with a functioning and normal-looking bleb. The patient returns at 1 month postop with an IOP of 38 mm Hg in the operated eye and a flat bleb. To rejuvenate the bleb and re-establish aqueous flow into the bleb, you perform a bleb needling revision at the slit lamp in your office. Can you bill for this procedure, and if so, how?

Answer

No, you cannot bill separately for this procedure. Trabeculectomy is a major surgery with a 90-day global period. The bleb needling revision was performed to manage the postoperative complication of elevated IOP due to early bleb failure. The procedure was performed in the office at the slit lamp and did not require a return trip to the operating room. Therefore, it is included within the global payment for the trabeculectomy and is not separately billable.

Case 3

Following a trabeculectomy for uncontrolled POAG, the patient initially has an uneventful postoperative course with a functioning and normal-looking bleb. The patient returns at 1 week postop with an IOP of 31 mm Hg in the operated eye and a shallow bleb. To allow for greater aqueous flow through the sclerotomy and into the bleb to lower the IOP, you perform a laser suture lysis at the slit lamp in a nearby ASC because you do not have a laser in your office. Can you bill for this procedure, and if so, how?

Answer

Yes, you can bill separately for this procedure. Trabeculectomy is a major surgery with a 90-day global period. The laser suture lysis is sometimes necessary in the postoperative care of trabeculectomy patients. But it could also be viewed as a procedure to manage the postoperative complication of elevated IOP due to either too many or overly tight sutures. The procedure was performed in the ASC and did require a return trip to the “laser suite” part of the ASC. Therefore, in this case, the laser suture lysis is separately billable. The surgeon should append modifier 78 (unplanned return to the operating room/procedure room by the same physician following initial procedure for a related procedure during the postoperative period).

Case 4

Following a repeat trabeculectomy for uncontrolled POAG, the patient returns beginning on postop day 1 for an injection of 5-FU to minimize synechiae formation in the bleb. This procedure is performed in a minor procedure room in your office. Can you bill for this procedure, and if so, how?

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Answer

Yes, you can bill separately for this procedure. Trabeculectomy is a major surgery with a 90-day global period. However, the 5-FU injections are staged services that are planned to be furnished at certain intervals during the postoperative period. In order to separately report the 5-FU injections, you should append modifier 58 (staged or related procedure or service by the same physician during the postoperative period). Therefore, the 5-FU injections are staged procedures and separately billable with modifier 58. In addition, the 5-FU drug product is also separately billable. Because the 5-FU would be compounded into small quantities for ophthalmic use, it would be reported with HCPCS code J7999 (Compounded drug, not otherwise classified) instead of HCPCS code J9190 (Injection, fluorouracil, 500 mg).

Case 5

Following the placement of an Ahmed shunt after a failed trabeculectomy for uncontrolled advanced POAG, the patient returns on postoperative day 1 with a shallow anterior chamber and an IOP of 4 mm Hg. You reform the patient’s anterior chamber by injecting viscoelastic into the anterior chamber, and this procedure is performed in a minor procedure room in your office. Can you bill for this procedure, and if so, how?

Answer

No, you cannot bill separately for this procedure. Glaucoma shunt placement is a major surgery with a 90-day global period. The injection of viscoelastic into the anterior chamber is a surgical procedure to manage hypotony following insertion of a glaucoma shunt — a not uncommon postoperative complication. The procedure was performed in a minor procedure room in your office and did not require a return trip to the operating room. Therefore, the anterior chamber reformation procedure is included within the global payment for the trabeculectomy and is not separately billable. Also, note that although the viscoelastic is injected similar to how a drug is injected, it is a medical device and is considered by CMS to be a bundled surgical supply and therefore not separately billable.

Case 6

A glaucoma patient on multiple medications undergoes implantation of a new MIGS device immediately following cataract surgery. The MIGS implantation procedure is described by a Category III CPT code. Based on comparisons to other intraocular surgeries, your Medicare Administrative Contractor has assigned a 90-day global period to the Category III code. During the first postoperative month, with the patient off all glaucoma medications, the patient’s IOP remains in the mid to high 20s, and you conclude that the MIGS device is not working adequately. You have faith in the device based on the clinical trial results and your experience with implanting the device in other patients. Can you bill for the second MIGS implantation procedure during the global period, and if so, how?

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Answer

Yes, you can bill separately for the second MIGS procedure. There are three categories of services that are not included in the global surgical payment that apply to the second MIGS procedure: 1. “Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery,” 2. “Clearly distinct surgical procedures that occur during the postoperative period which are not re-operations or treatment for complications,” and 3. “Treatment for postoperative complications requiring a return trip to the operating room.” The second MIGS procedure could be considered an “added course of treatment” and a “distinct surgical procedure” that is not a re-operation because the second MIGS involves another device inserted in a new location — a separate and distinct procedure relative to the first MIGS procedure. Also, the second MIGS procedure could be viewed as treatment of a complication that requires a return trip to the OR. In reporting the second MIGS procedure, you would append modifier 78 (unplanned return to the operating room/procedure room by the same physician following initial procedure for a related procedure during the postoperative period).

Case 7

You perform cataract surgery with concurrent MIGS device implantation. On postoperative day 1, the device appears to be functioning normally and the IOP is 16 mm Hg. At the 1-month postoperative visit, the IOP is 29 mm Hg and you notice that a membrane has formed over the MIGS device port. You use a Nd:YAG laser that is located in your office in a dedicated room that is only used for laser procedures. Can you bill for the YAG laser procedure, and if so, how?

Answer

Yes, you can bill separately for the laser procedure; modifier 78 applies. The regulation that supports billing for this procedure states, “Treatment for postoperative complications requiring a return trip to the operating room. An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).” Note that a “laser suite” is a room dedicated to the primary purpose of performing laser procedures. It is not a multipurpose exam room or minor treatment room in which you sometimes happen to use a portable laser.

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Key takeaways

1. It is important to understand what services are either in or out of the global period. Follow the guidance in CMS’ Global Surgery Booklet and its online manuals.

2. The site of service (ie, use of an operating room vs. the physician’s office) is a key determinant of whether a procedure in the postoperative period is separately billable.

3. Do not alter your practice patterns in order to circumvent the global period rules.

4. In ambiguous cases, seek guidance from the payer or a coding professional.

Disclosures: Corcoran reports he is president of Corcoran Consulting Group. McInnes reports no relevant financial disclosures.