How to Report Complication Visits Outside Global Package?
Find out how to properly report complication visits outside the global package, ensuring accurate billing and compliance with medical coding rules.
OB/GYN Medical Billing & Coding Alert
Did you know that you can report complication visits outside the standard global OB package? Many practices need to look into this opportunity, potentially missing out on rightful reimbursements for the specialized care your OB/GYN provides. Whether the complications occur before or after delivery, these visits are billable separately, ensuring your practice is compensated for the additional time and expertise required. Accurate coding is crucial—especially for high-risk or complicated obstetrical care. By mastering ICD-10 codes and understanding the nuances of documentation, you can maximize reimbursements while maintaining compliance. Don’t let these opportunities slip by; learn how to report complicated visits effectively and enhance your practice’s revenue.
What Is a Global Surgical Package?
The global surgical package is a policy established to standardize Medicare payments across all jurisdictions. This package ensures that Medicare Administrative Contractors (MACs) pay consistently for services related to surgical procedures. The purpose is to prevent discrepancies in Medicare payments, ensuring they are neither too high nor too low for the intended services.
The global surgical package includes all the necessary services provided by a physician or members of the same specialty group, both before, during, and after a surgical procedure. This policy also applies to situations involving bilateral surgeries, multiple surgeries, co-surgeons, and team surgeons. Under this system, physicians in the same group practice, sharing the same specialty, are required to bill and accept payment as if they are a single entity. This ensures uniformity in billing and payments across the board.
How to Report Complication Visits Outside Global Package? - Guideline
When faced with two potential coding options, it's important to consider Relative Value Units (RVUs). Just like when you factored in the obgyn’s approach, uterine size/weight, and the extent of hysterectomy procedures, you should also account for any additional procedures the OBGYN performs. RVUs help determine the appropriate code based on the work involved in both the primary and any additional procedures, ensuring accurate reimbursement.
Hysterectomy With Stress Incontinence Procedure? Look at These Options
When an obgyn performs a bladder and/or urethra fixation for stress incontinence along with a hysterectomy, you have two coding options. Depending on the fixation type, your physician may refer to it as a "Marshall-Marchetti-Krantz," "Burch," or "Pereyra" procedure.
For an abdominal approach, the correct code is 58152 (Total abdominal hysterectomy, with or without removal of tubes and/or ovaries, with colpo-urethrocystopexy [e.g., Marshall-Marchetti-Krantz, Burch]).
For a vaginal approach, use 58267 (Vaginal hysterectomy, for the uterus 250g or less, with colpo-urethrocystopexy.
Hysterectomy With Vaginectomy? Check Out These Codes
Hysterectomies involving partial or total vaginectomies (colpectomies) have specific codes.
For an open hysterectomy, use 58200 (Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tubes and/or ovaries). This code covers the removal of the uterus and includes a partial vaginectomy and possibly removal of parametrial tissue, often performed when endometrial cancer has spread to the cervix or parametrium.
For radical procedures,
- 58210 (Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling, with or without removal of tubes and/or ovaries) and
- 58548 (Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling, with removal of tubes and ovaries, if performed) also include removal of parametrial tissue and a vaginectomy of the upper one-third of the vagina.
For a vaginal approach, use 58275 (Vaginal hysterectomy, with total or partial vaginectomy), 58280 (with repair of enterocele), or 58285 (Vaginal hysterectomy, radical [Schauta type operation]).
Hysterectomy With Lymph Node Sampling? Underline These Codes
When an obgyn performs para-aortic and pelvic lymph node sampling, which is a lymph node biopsy, it can only be done via an abdominal approach along with a hysterectomy. For this service, report 58200. This is also referred to as a “modified radical” abdominal procedure, which includes a partial vaginectomy.
If the obgyn performs a bilateral pelvic lymphadenectomy and para-aortic lymph node sampling, use 58210 for the abdominal approach, or 58548 for the laparoscopic approach.
Ovarian or Endometrial Cancer Broadens Your Choices
When dealing with ovarian or uterine cancer, four other codes may better reflect the procedures performed. The appropriate code choices include:
- 58951 (Resection [initial] of ovarian, tubal, or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy)
- 58953 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy, and radical dissection for debulking)
- 58954 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy, and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy)
- 58956 (Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy)
Enterocele Repair Codes
Enterocele repair combination codes include hysterectomies, and for a vaginal approach, the following codes apply:
- 58263 (Vaginal hysterectomy, for uterus 250 g or less; with the removal of tube(s) and/or ovary(s), with the repair of enterocele)
- 58270 (Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele)
- 58280 (Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele)
- 58292 (Vaginal hysterectomy, for uterus greater than 250 g; with the removal of tube(s) and/or ovary(s), with repair of enterocele)
- 58294 (... with repair of enterocele)
Note: A vaginal hysterectomy with an abdominal enterocele repair does not have a combination code, and OBGYNs should generally avoid this combination.
Hysterectomy Scenario Breakdown
Scenario: A vaginal hysterectomy is performed with a uterus weighing less than 250 grams, no removal of tubes or ovaries, combined with enterocele repair and colpourethrocystopexy. How should this be coded?
Answer: You have two coding options:
- Option 1:
- 58270 (Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele)
- 51840 (Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple)
- This option provides a total of 26.66 work RVUs (15.30 RVUs for 58270 and 11.36 RVUs for 51840). According to the National Correct Coding Initiative (NCCI), this combination is acceptable, and it offers better chances for reimbursement.
- Option 2:
- 58267 (Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type], with or without endoscopic control)
- 57268 (Repair of enterocele, vaginal approach [separate procedure])
- This option results in 25.93 work RVUs (18.36 RVUs for 58267 and 7.57 RVUs for 57268). Although an acceptable combination, it has fewer work RVUs compared to Option 1.
Conclusion: Based on the work RVUs, Option 1 is the better choice.
Choosing the Best Preeclampsia Code
When coding for preeclampsia, ensure to choose the correct code based on the documentation and trimester:
- Mild to moderate pre-eclampsia:
- O14.00 (Unspecified trimester)
- O14.02 (Second trimester)
- O14.03 (Third trimester)
- Severe pre-eclampsia:
- O14.10 (Unspecified trimester)
- O14.12 (Second trimester)
- O14.13 (Third trimester)
- Unspecified pre-eclampsia:
- O14.90 (Unspecified trimester)
- O14.92 (Second trimester)
- O14.93 (Third trimester)
Additionally, O87.2 (Hemorrhoids in the puerperium) should be reported when applicable.
Best Timeframe for Submitting Claims
You have two options for submitting the claim:
Option 1: After Delivery
- Most coders recommend submitting claims after delivery when the complications can be fully quantified. By waiting until after delivery, you can ensure all extra services outside the global OB package are coded accurately. This helps prevent losing revenue by underreporting the charges.
- Best Practice: Implement a system to review patient records carefully to capture any additional charges outside the global package.
Option 2: During Pregnancy
- If timely filing is a concern, you might choose to submit claims during the pregnancy. However, this approach risks denials, as many payers deny visits that occur in the antepartum period. You can appeal these denials after delivery if necessary.
- Note: If the patient delivers early and the number of antepartum visits is within the global OB package, you may need to return overpayments.
- Red Flag: Some payers have specific guidelines regarding services outside the global OB package, so check with them to determine which option is best.
Keep in Mind
- The term "high-risk" refers to an active complication or a pregnancy at higher risk due to a history of issues, not just a concern about the pregnancy’s outcome. Payers will cover complications, but won’t offer extra reimbursement for concerns that aren't backed by active complications.
What Are Complication Visits Outside the Global Package?
Complication visits outside the global OB package refer to additional visits needed when a patient experiences complications before or after delivery that require more care than is typically covered under the standard global OB package. These complications could involve high-risk conditions or unexpected issues such as pre-eclampsia or postpartum complications like hemorrhoids. Reporting these visits separately from the global package can result in increased reimbursement for the additional care your OBGYN provides. However, payers are often more scrutinizing of these claims, so precise and accurate coding is essential.
To achieve the highest ICD-10 accuracy, it’s crucial to link the ICD-10 code to the corresponding E/M code on the CMS-1500 claim form (boxes 21 and 24E). This ensures the payer understands the medical necessity for the additional services. For example, if a patient develops pre-eclampsia during pregnancy, you must accurately code both the diagnosis and the treatment or services provided, whether during the pregnancy or after delivery. You can include these additional services either with the global OB claim or submit them as separate claims, depending on when the complication occurs.
Example Breakdown
Consider a 33-year-old patient, gravida 3, para 2, who experiences pre-eclampsia and requires 19 visits, which includes six additional visits beyond the usual 13. Three of these visits have documentation supporting the use of a 99213 code, while the other three require a 99214 due to more extensive care. After delivery, the patient also develops a thrombosed hemorrhoid and is treated in the office.
ICD Relevant Codes
The OB/GYN documents these additional services and correctly links them with the appropriate ICD-10 codes, such as:
- O14.00 – Mild to moderate pre-eclampsia, unspecified trimester
- O14.02 – Mild to moderate pre-eclampsia, second trimester
- O14.03 – Mild to moderate pre-eclampsia, third trimester
- O14.90 – Unspecified pre-eclampsia, unspecified trimester
- O14.92 – Unspecified pre-eclampsia, second trimester
- O14.93 – Unspecified pre-eclampsia, third trimester
- Z37.0 – Single live birth
- O87.2 – Hemorrhoids in the puerperium
This ensures the OBGYN receives reimbursement for the extra work.
When to Submit Your Claim?
There are two options for submitting claims for complications outside the global OB package. The first option is to submit the claim after delivery once you can confirm how many additional visits occurred beyond the global package. This method is often preferred because it allows for a full review of the patient’s complications after delivery to determine the extent of the extra care required.
Alternatively, you can report the additional visits during the pregnancy as the complications arise, according to CPT® guidelines. In this case, you must ensure the ICD-10 codes align with the CPT® codes for the services provided, such as the hemorrhoids diagnosis aligning with the code for the procedure performed. This option may help avoid issues with timely filing rules applied by some payers.
Important Considerations
It's important to note that some payers have specific guidelines for reporting complications outside the global OB package, so it's essential to verify with them to determine which approach to take. Additionally, keep in mind that the term "high-risk" refers not only to current complications but also to concerns based on the patient’s medical history. Payers typically recognize complications but will not pay extra for simply worrying about potential issues during the pregnancy.
By ensuring that complications are documented and coded accurately, OBGYNs can increase their chances of receiving appropriate reimbursement for the additional care they provide while maintaining compliance with payer policies.
Maximize Your Complication Visits Outside Global Package Revenue with BillingFreedom’s Expert Billing Solutions
BillingFreedom is your trusted partner for OB/GYN medical billing services, especially when navigating complex billing scenarios. With our deep expertise in OB contracts and coding, we ensure your practice is properly compensated for every service, including high-risk and complicated obstetrical care. Whether you're dealing with global surgical packages, complication visits, or intricate procedures like hysterectomies, we master the nuances of IUD coding and hysterectomy codes to maximize reimbursements. Our team is well-versed in identifying and reporting complications before and after delivery, ensuring that every eligible charge is captured accurately without missing any revenue opportunities.
Trust BillingFreedom to handle the complexities of OB/GYN billing with precision. We are specialists in navigating the intricate details of OB billing, from high-risk care to preeclampsia coding and beyond. Our experience ensures that your practice stays compliant while optimizing your revenue, eliminating costly errors and denials. With BillingFreedom, you can focus on providing excellent patient care while we expertly manage the billing process for all your OB/GYN services. Let us help your practice thrive—contact us today!
For more details about our exceptional medical billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472.
Your financial tranquillity is our priority!
FAQs
Does the post-operative reporting requirement apply to pre-operative visits that are part of the global period for procedures with 90-day global periods?
No, the post-operative reporting requirement applies only to post-operative visits. Pre-operative visits that fall within the global period do not require separate reporting.
What if post-operative care is transferred to another practitioner and billed with modifier 55?
Suppose post-operative care is transferred to another practitioner and billed with modifier 55. In that case, the practitioner who takes over the post-operative care should report CPT code 99024 for post-operative visits, provided they meet the reporting requirements. This includes practicing in a state where reporting is required and being part of a practice with 10 or more practitioners.
What if I furnish other services to the same patient on the same day?
Suppose other services are furnished to the same patient on the same day. In that case, post-operative visits covered by the global period must still be reported if they would otherwise be separately reportable outside the global period. If multiple post-operative visits are provided on the same day, only CPT code 99024 should be reported once, following the same guidelines as E/M rules. When a post-operative visit occurs on the same day as an unrelated E/M service (billed with modifier 24), CPT code 99024 should be used for the post-operative visit. This reporting requirement remains the same as the care included under the global payment, and services not covered by the global period must adhere to normal billing rules.
If a service provided by hospitalists or intensivists to a patient within a global period is reported using an E/M code, would that now be reported using 99024 instead?
The new reporting requirement keeps what is included under the global payment. CPT code 99024 should only be reported for post-operative visits that are not otherwise separately reported because they are part of the global period. If a service provided by hospitalists or intensivists during the global period is currently not reported due to being part of the global payment, then CPT code 99024 should be used. This ensures that the post-operative care is properly documented while other services continue to follow normal billing rules.
How does Medicare classify global surgery?
Medicare classifies global surgery into three types based on the number of post-operative days:
0-Day Post-Operative Period (Endoscopies and Some Minor Procedures)
- There is no pre-operative period.
- No post-operative days are included.
- Generally, a visit on the procedure day is not payable separately.
10-Day Post-Operative Period (Other Minor Procedures)
- There is no pre-operative period.
- A visit on the procedure day is not separately payable.
- The total global period lasts for 11 days, which includes the surgery day and the 10 days immediately following.
90-Day Post-Operative Period (Major Procedures)
- A 1-day pre-operative period is included.
- The procedure day is not separately payable.
- The total global period lasts 92 days, counting the day before the surgery, the day of the surgery, and the 90 days immediately following.
Note: Under specific conditions in the Comprehensive Care for Joint Replacement Model (CJR), surgeons or other practitioners can separately bill for a post-discharge home visit. During the 90-day postoperative period, all other global surgery billing rules apply.
Ready to Boost Your Revenue?
Save your hard earned money, register, before it's gone.