Ensuring proper global payments

Ear, Nose & Throat Journal, July, 2003 by Steven F. Isenberg

Medicare carriers and others that follow Medicare rules recognize two types of global payments: those for major surgery and those for minor surgery or endoscopic procedures that do not involve an incision.

Covered visits for major surgery are those that occur the day before surgery and the day of surgery and for visits that take place during a 90-day postoperative period (modifier 57). Visits related to the decision to perform surgery are not covered.

Covered visits for minor surgery or nonexcisional endoscopic procedures are those that occur on the day of the procedure and for a 10-day postprocedure period (modifier 25). Again, visits related to the decision to perform the procedure are not covered.

However, not all carriers follow Medicare rules. Because carriers define these concepts independently of one another, surgeons must be sure to understand each individual payer's rules. Your practice's financial software should warn you before a visit occurs if a claim will be rejected because it does not meet a carrier's definitionof a covered global or follow-up visit (figure). Such a notification will prevent your office from filing a claim that will be denied, and it can serve to remind the physician to modify the visit appropriately if the patient is being seen for another, separately identifiable problem during the global period (modifier 24 for the visit, modifier 79 for the service).

The duration of global periods for some common otolaryngology procedures are 10 days for tympanostomy tube placement (CPT code 69436), 90 days for tonsillectomy and adenoidectomy (42820/42821) and for septoplasty (30520), and zero days for tracheostomy (31600) and control of nasal hemorrhage (3090 1-30906).

Dr. Isenberg is an otolaryngologist in private practice in Indianpolis; sisenberg@good4docs.com