Documenting and Reporting Postoperative Visits

CPT® 99024 was introduced by the American Medical Association (AMA) with an effective reporting date of January 1, 2013. The associated code description is as follows:,&nbsp

“Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure”

To fully understand this code description, one must also understand the definition of the global surgical package, which CPT® describes as: 

Of note, Medicare published their own definition of the global surgical package (see Chapter 12, Section 40.1 of the Medicare Claims Processing Manual-Pub. 100–04), which differs from the CPT® surgical package. The surgical package policy applied to an individual claim is determined by the patient’s insurance company’s published policies.Payers without published policies must adhere to the CPT® guidelines.

Prior to 2017, pre/postoperative services with a zero-dollar charge, were not submitted on claims. Because of this, a proper analysis of the quality and quantity of services that make up a global surgical package was not possible, as there was a deficit in the data that showed postoperative services. In 2015, Medicare proposed a change in the global surgical package to return all surgical procedures to a zero-day global period to promote a more accurate valuation of surgical services through coding data. However, Section 523(a) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114–10, enacted April 16, 2015) added section 1848(c)(8)(A) of the Act, prohibited the Secretary from implementing this change. 

Instead, on January 1, 2017, Medicare required specific large provider groups, identified by them, to report via claim, all preoperative and postoperative services provided during the global surgical period. Although the requirement was only specific to certain large provider groups and not all Medicare providers, all Medicare contracted providers were encouraged to do likewise. This policy was strategic to facilitate a more accurate valuation of more than 4,000 surgical procedures assigned a 0, 10, or 90-day global period.

Each surgical procedure is assigned either a 0, 10, or 90-day global period; however, according to the global surgical package, the day of the procedure is considered bundled into the procedure for 0-day and 10-day global periods, which means technically the 10-day global period is actually an 11-day global period (day of the procedure and the 10 days following the procedure). For 90-day global periods, which are considered to be major surgical procedures, the day prior to the surgery, the day of the surgery, and 90 days following the surgery, are included in the global period, essentially making a 90-day global period actually a 92-day global period. 

Preoperative services performed on the day of a 0-day or 10-day surgical procedure are bundled into the procedure itself. As an example, let’s review the following patient scenario: 

Scenario: A patient has an appointment to have their nails trimmed in the office. The physician documents a history related to the patient’s chronic conditions and how they impact his ability to trim his own nails, examines the patient’s nails, and determines there are 8 that need to be trimmed. The provider documents the procedure where the nails are trimmed, including the method used, the nails trimmed, and the outcome and any instructions on nail care to the patient. 

Code:11721 - Debridement of nail(s) by any method(s); 6 or more is reported but not anEvaluation and Management (E/M) service code. The reason being, is that this was a scheduled procedure and all of the history and exam were related to why the patient has the condition, needs the service performed, and the actual performance of the service, all of which are considered the preoperative workup included (bundled) into the service itself. 

Same Day Surgeries

Currently, there are 1,190 surgical procedures with a zero-day global period, 468 surgical procedures with a 10-day global period, and 3,743 major surgical procedures with a 90-day global period. Code 99024 is used to report postoperative services, beginning with any postoperative care provided on the day of the surgery (after the surgery has been performed) and each visit thereafter, where postoperative care is provided through the end of the assigned global period.  For same day surgeries (SDS), that means all care related to admitting the patient, postoperative care up until discharge, and inclusive of the discharge services. The same applies to admission and discharge services, as well as inpatient E/M services provided to a patient in the inpatient hospital setting. Facilities who accurately report all postoperative services with 99024 during the global period would also report 99024 for any admission and discharge services, instead of the usual CPT codes for those services, and all are bundled into the surgical package, unless specific surgical or patient care for other conditions or complications is provided that is beyond what is covered in the surgical package. 

However, it should be noted that if the surgeon is billing for Evaluation and Management services, during the global period, that are unrelated to the surgical procedure and global period, and the documentation supports the clear distinction of these services, the provider may report the E/M service with modifier 24 to specify it is a distinct and separately billable service provided during the global period. 

Splitting Surgery and Postoperative Care

Occasionally, the surgeon who performs the surgery is not available to perform the preoperative and postoperative care. This can be because pre and postoperative services are provided in a different state than the surgeon resides and the patient has returned home after surgery to get postoperative care by their own physician, or another reason exists. Be sure to check individual payer policies related to splitting the surgical global package components to ensure coverage, medical necessity, documentation requirements, and modifier use for reporting claims. 

When the global surgical package is split between providers for Medicare beneficiaries, each provider will report the surgical CPT code and the modifier that applies to the services they are providing and in the narrative box on the claim, will provide the details of the services and service dates they are providing to the patient. Novitas, and other Medicare Administrative Contractors (MACs) have provided published documents to review this process in detail.

Documentation

Clear documentation is very important in ensuring accurate reimbursement for services rendered, whether for the entire global surgical package or when it has to be split between providers. An operative report that clearly describes the pre/postoperative diagnosis, name of the procedure, and the details of how it was performed, is a must have for claims submission and medical necessity. Likewise, each postoperative report should contain language that indicates the patient is presenting for a postoperative visit, including the postoperative date (e.g., POD#7, status post day 7) and the surgical procedure they had done, including the date the procedure was performed. This facilitates proper coding for the global period and an accurate reflection of postoperative care provided to the patient following surgery. 

Additionally, be sure to document any postoperative care, such as: 

• Patient complaints, symptoms, or complications directly related to the surgical procedure.
• Examination of the patient, especially the body area or organ system impacted by surgery.
• Medications or treatments that have been prescribed, including pain management. 
• Follow-up testing or imaging ordered to check the patient’s status after surgery.
• Any conditions, symptoms, or treatments that are unrelated to the surgical procedure that may qualify for appending modifier 25 to the E/M service.

Separately Reportable E/M Service on the Day of a Postoperative Visit by the Same Provider

When a postoperative visit turns into an E/M service for an unrelated condition, the provider may be eligible for payment if the documentation supports a separately, identifiable E/M service as well as the postoperative visit service. Providers often combine these two services in a single report; however, to ensure accurate payment and reduce confusion that may occur during an audit, we recommend either documenting the postoperative care first and in the same note, just separated from it, document a complete E/M service note as well for the unrelated problem. Providers may also choose to simply document two separate reports, one for the postoperative visit and another for the separately identifiable E/M service on the same date. To ensure the E/M service is paid, when the documentation qualifies the service, report modifier 24 (unrelated E/M by the same physician during the postoperative period) with the E/M service code to clarify it is an unrelated service. If supporting documentation is requested by the payer, be sure to send both reports, the postoperative note and the E/M service note for clarity. 

Of note, there is no NCCI edit between 99024 and E/M service codes indicating that if both a postoperative visit and an unrelated E/M service are performed on the same day by the same physician/provider, they may be reported on the same claim; however, be sure to append modifier 24 to the E/M service code to instruct the payer that the provider documentation supports unbundling the E/M service from the global period for payment.

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