Billing for In-Office Surgical Procedures
An expert demystifies a confusing part of the reimbursement process.
By Mary Pat Johnson, C.O.M.T., C.P.C., C.O.E., San Bernardino, Calif.

Getting properly reimbursed for in-office surgical procedures can be a challenge because Medicare's rules vary depending on what procedure is being performed and when and where it's performed. (Other third-party payers aren't required to follow Medicare's policies, but they often do.)

Here, I'll explain the application of Medicare's global surgery policy to in-office surgery for major and minor procedures. I'll also cover the special rules pertaining to injections and supplies, and I'll provide a list of the relevant modifiers and some tips on chart documentation.

Global fees

In 1992, Medicare instituted a global surgery policy as part of physician payment reform. The global surgery rules dictate that the listed surgical services are "package deals." Under this policy, a single fee is paid for all necessary services that would normally be furnished by the surgeon before, during and after the procedures. The Medicare-approved amount for these procedures includes payment for the following services related to the surgery (as long as they're furnished by the surgeon):

• preoperative visits after the decision is made to operate, beginning with the day before surgery for a major procedure and the day of surgery for a minor procedure
• intraoperative services that are usual and necessary to the surgical procedure
• additional medical or surgical services required by the surgeon during the postoperative period to treat a complication, but not requiring a return to the operating room
• follow-up visits during the postoperative period that are related to recovery
• most surgical supplies. (Exceptions include a surgery tray for a temporal artery biopsy and injectable medications.)
  Certain services are not included in the global surgical package. These are paid separately:
• the initial consultation or evaluation of the problem by the surgeon to determine the need for surgery
• services of other physicians, unless a co-management arrangement has been established
• visits unrelated to the diagnosis for which the surgery is performed, unless the visits are a result of complications
• diagnostic tests and procedures
• clearly distinct surgical procedures that are not re-operations or treatment for complications (staged procedures)
• treatment for complications that require a return trip to the operating room.

Major vs. minor surgery

The global surgery policy has different rules for reimbursing major and minor surgery. Because both are sometimes performed in-office, I'll discuss the reimbursement rules that apply in either situation.

Major surgery. Major surgery is defined as any procedure that has a 90-day postoperative period. Most major surgery procedures are performed in a hospital or outpatient surgery facility, but some, such as ophthalmic laser procedures, may be performed in an office setting.

Minor surgery. Minor surgery is defined as any surgical procedure with a zero or 10-day postoperative period, such as:

• foreign body removal (65222)
• punctal occlusion with plug (68761)
• correction of trichiasis (67820)
• chalazion excision (67800).

Note that some of these procedures are "starred," meaning that an asterisk appears next to the code in CPT. These are not traditionally paid under the global surgery policy.

Also, the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) has announced its intention to assign a 10-day post-op period to laser trabeculoplasty (65855) starting in 2002, instead of a 90-day post-op period. This will make laser trabeculoplasty subject to the minor surgery rules.

Reimbursable office visits

Whether or not you can be reimbursed for an office visit that takes place on the day of an in-office procedure depends on two things: whether the surgery is major or minor, and the reason for the office visit.

An exam performed to determine the need for a major surgery is reimbursed separately from the procedure. For example, your patient presents with increased intraocular pressure (IOP) and dangerously narrow angles. You plan to perform a peripheral iridotomy (66761) in the office immediately. Both the exam and the laser treatment are reimbursable. (When filing your claim, the exam code must include modifier -57.)

For minor surgery procedures, the exam performed on the same day as the procedure is usually considered to be incidental and isn't paid separately. For example, suppose a patient has a history of dry eyes and has had no relief from artificial tears. She presents today for punctal occlusion with plugs (68761). The office visit is considered incidental to the procedure and isn't reimbursed separately.

On the other hand, if the exam on the same day focused on a separate condition, separate reimbursement would be made. For example, when a patient with glaucoma and dry eyes has punctal plugs inserted in conjunction with a previously scheduled visit to monitor the glaucoma, the exam code would be appended with modifier -25 and submitted with a diagnosis of glaucoma (365.xx).

It's easy to see how a distinctly different diagnosis satisfies the requirement for a "separately identifiable service," yet CPT and the CMS do not require another separate diagnosis to use modifier -25. There are some cases in ophthalmology in which the exam would be considered a separately identifiable service if it focused on the same condition as the minor surgery procedure.

Follow-up visits during the postoperative period are not usually reimbursed separately because payment is included in the global surgery fee for both major and minor surgeries. The exception is care for an unrelated condition. The exam may be reimbursed, but the modifier -24 must be appended to the CPT code to signal the carrier. For example, suppose your patient has a history of chronic open angle glaucoma OU and had cataract surgery OD 10 weeks ago. Today's visit includes a re-evaluation of the pre-existing COAG and the post-op check of the right eye. Your claim for the office visit is warranted and would use COAG (365.11) as a diagnosis.

Under the global surgery concept, post-op care for a related condition isn't separately reimbursed. For example, a post-op exam to treat cystoid macular edema (CME), an infrequent complication of cataract surgery, would be considered related to the cataract surgery. Modifier -24 would not apply.

Billing for injections

Injections are considered surgical procedures; depending on the timing and the reason they're performed, they may be reimbursable. The CMS considers most injections to be minor procedures, but a few, such as the chemodenervation of extra-ocular muscle (67345), are considered major procedures.

A common mistake when billing for injections is forgetting to submit a claim for the supply of the drug that's injected. (Injectable agents are described by their own HCPCS code.)

For example, suppose you need to treat a post-cataract patient who has cystoid macular edema (CME), using a retrobulbar injection (67500). If performed in-office during the post-op period, the injection itself is included in post-op care; however, the drug you inject can be billed separately using the appropriate HCPCS code (Jxxxx). (Of course, reimbursement would be made for both the injection and the supply if the injection were performed outside the post-op period.)

The reimbursement you receive for the supply may depend on the amount injected. In some cases, a different HCPCS code is used to describe the same drug, depending on the quantity. For example, when injecting methylprednisolone acetate:

• J1020 denotes a 20 mg injection
• J1030 denotes a 40 mg injection
• J1040 denotes an 80 mg injection.

Separate reimbursement for the drug can be especially important when the cost of the drug is a factor. For example, botulinum toxin type A (Botox) injections for the treatment of focal muscle spastic disorders and excessive muscle contractions are reimbursable when the injection is medically necessary. (The injection and the supply should be identified separately on the claim form for reimbursement.)

Currently, carriers are even willing to reimburse for the unused portion of Botox because of its short shelf life. To avoid waste, you're encouraged to schedule several patients at the same time; if three patients are scheduled for Botox injections on the same day, you can use the same 100-unit vial for all three patients. (The number of units injected should be listed on each procedure's claim form.) If excess supply still remains after performing injections on all 3 patients, the wasted amount can be billed on the last claim form.

Billing for supplies

Although an HCPCS code for a sterile surgical tray exists (A4550), this item is rarely reimbursed separately. At present, the only ophthalmic procedure that allows additional payment for a surgical tray is a temporal artery biopsy (37609).

Until January 2002, silicone punctal plugs are paid separately when identified using HCPCS code A4263. However, effective January 1, 2002, the CMS will bundle payment for the silicone plugs and the physician's professional fee for inserting the plugs (68761). (Payment for collagen plugs has always been bundled with the professional fee.)

Staying in the clear

Not every third-party payer follows Medicare's reimbursement rules; some have different post-op periods, different rules for same-day eye exams, or different payment schedules for supplies and surgical trays. For that reason, it's important to review the policies of each payer.

Understanding these rules (and their variations) will help to ensure cleaner claims -- and that you receive proper reimbursement for the services you provide.

Mary Pat Johnson is a senior consultant with Corcoran Consulting Group. She can be reached at 800-399-6565, or via e-mail at mpjohnson@corcoranccg.com.