When Is a Decision Reimbursable?

Many commercial carriers have providers in an uproar regarding the carrier's interpretation of the global surgical package. Here is the scenario:
Patient presents to the Emergency Room for evaluation, and after evaluating the patient, the ER provider determines that the patient's condition warrants an evaluation by a surgeon. The surgeon comes to the ER, evaluates the patient, and makes a decision for surgery. The patient is immediately taken to the OR for surgical intervention.

When reimbursing this service, many carriers are not allowing two (2) E&M visits on the same date of service and therefore are bundling the surgeon's consult with the global surgical package. These carriers are not denying the ER provider's charge, as they agree it is reimbursable; they are only denying the surgeon's encounter. The carrier's interpretation of these services labels them as "preoperative services."

Providers who are affected by this determination should appeal this claims consideration each time a claim is denied. The basis of such an appeal could reference the following:
AMA Guidelines (CPT Guidelines): In the surgical guidelines section preceding the surgery section, the guidelines include a description of the global surgical package. Within these guidelines there is a definition of what CPT interprets as preoperative services. The definition is as follows:
"Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical)."

Based on the definition, the services in question are clearly not after the decision for surgery has been made. Therefore, CPT guidelines would indicate this service as a billable and reimbursable encounter.

CMS Guidelines: Although not all carriers adhere to CMS rules and guidance, many do, and their rules are typically a benchmark for all medical services. Chapter 12 section 40.1 of the benefit policy manual defines global surgical services according to CMS rules and guidelines. CMS' rules echo the CPT's definition of preoperative services as those services rendered after the decision for surgery has been made.

The guideline states:
"Preoperative Visits  Preoperative visits after the decision is made to operate beginning with the day before and the day of surgery for major procedures and the day of surgery for minor procedures."

Additionally, CMS' guidance also includes details of what is not part of the global surgical services. The first identifier CMS includes as not part of the global surgical package is the encounter in which the decision for surgery has been formed.

The guideline is as follows:
"The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure."

Currently, many carriers are forming a different opinion, but are not doing this based on a published medical policy. Medical directors are being inundated with requests for reconsideration. Obviously, a carrier can make whatever policy they want, but such a drastic policy change should have warranted specific notification to specialists who would be most affected by such a policy.

Decision making for a major procedure (90 day global procedure) is considered moderate to high level complexity, yet carriers are saying that service is not a justified separately reimbursed service. If the consulting provider did not take the patient to surgery, this "lower level" medical decision making supports a reimbursable service according to the interpretation of this policy.

Continued push by carrier policies to bundle services and additionally decrease reimbursement continue to put a financial burden on providers, and encourage non-compliance in practices such as spacing out services to prevent such bundling.

You are encouraged to check recent remittances for this bundling edit. Check behind billing staff, who may not completely understand global packages, and see if your recent claims have been denied  then appeal! Appeal to the highest level. Acceptance and tolerance of such policies by practices condone the actions of these carrier changes.
Mrs. DeConda is the Director of Coding and Reimbursement for DoctorsManagement as well as Director of the National Alliance of Medical Auditing Specialists. She has over 15 years extensive experience with auditing of all medical specialties, practice management, provider and employee education, billing, fee schedules, day-to-day office operations, marketing, and leadership. She is sought after as a consultant for numerous physician offices and an advisor to other medical associations.