Prepayment Edits to Detect Separate Billing of Services Included in the Global Package

In addition to the correct coding edits, A/B MACs (B) must be capable of detecting certain other services included in the payment for a major or minor surgery or for an endoscopy. On a prepayment basis, A/B MACs (B) identify the services that meet the following conditions:

• Preoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure; or

• Same day or postoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure or endoscopy;
and -

• Services that were furnished within the prescribed global period of the surgical procedure;

• Services that are billed without modifier “-78,” “-79,” “-24,” “25,” or “-57” or are billed with modifier “-24” but without the required documentation; and

• Services that are billed with the same provider or group number as the surgical procedure or endoscopy. Also, edit for any visits billed separately during the postoperative period without modifier “-24” by a physician who billed for the postoperative care only with modifier “-55.”

A/B MACs (B) use the following evaluation and management codes in establishing edits for visits included in the global package. CPT codes 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99271, 99272, 99273, 99274, and 99275 have been transferred from the excluded category and are now included in the global surgery edits.


Evaluation and Management Codes for A/B MAC (B) Edits

92012
92014
99211
99212
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99261
99262
99263
99271
99272
99273
99274
99275
99291
99292
99301
99302
99303
99311
99312
99313
99315
99316
99331
99332
99333
99347
99348
99349
99350
99374
99375
99377
99378


NOTE: In order for codes 99291 or 99292 to be paid for services furnished during the preoperative or postoperative period, modifier “-25” or “-24,” respectively, must be used to indicate that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed.

If a surgeon is admitting a patient to a nursing facility for a condition not related to the global surgical procedure, the physician should bill for the nursing facility admission and care with a “-24” modifier and appropriate documentation. If a surgeon is admitting a patient to a nursing facility and the patient’s admission to that facility relates to the global surgical procedure, the nursing facility admission and any services related to the global surgical procedure are included in the global surgery fee.