There was a very important question recently posted, “Since the global period for a toe amputation is now zero days, does that mean I bill for removing sutures in the office when I do a follow up visit in 14 days? Billing for this seems very uncomfortable to me.” As a Certified Professional Coder (CPC), Certified Surgical Foot and Ankle Coder (CSFAC) and as a Certified Professional Medical Auditor (CPMA), I had to mostly disagree fundamentally with a colleague’s previously posted response.
Points of Fact we are in agreement:
1) The fact is that the global period changed for two amputation CPT codes on January 1, 2021, the two CPT codes are:
CPT code 28820 is defined as: Amputation, toe; metatarsophalangeal joint
CPT code 28825 is defined as: Amputation, toe; interphalangeal joint
2) The global period changed to a ZERO "0" day global procedure for both CPT codes.
The following information is being provided to you for a better understanding. One must think about the answers given by others. A point to make is that I and many of the coding leaders have spoken to cannot agree with this colleagues interpretation.
Counterpoint #1:
1) My colleague stated "Being blunt and to the point, when the procedure was performed, the suturing of the surgical site is not separately reimbursable. It is considered to be part of the procedure. The surgeon put them in. The surgeon takes them out." Rebuttal: Well, there is more to "0" global and I am sure the person asking the question did not relate everything they did in their posting and was very matter of fact about just saying "suture removal at 14 days". Let's dive deep into what CMS classifies as "0" day global to better understand this concept and the way the 2 amputation codes changed your documentation going forward.
a) A 0-day global means there is no pre-operative period and no post-operative days. That is, the global package applies for one day, only (the day of the procedure or service). Best reference: Global Surgery Booklet (cms.gov) "For zero day post-operative period procedures, post-operative visits beyond the day of the procedure are not included in the payment amount for the surgery”.
b) These E&M visits are separately billable and payable if you meet the criteria (please keep reading). For more information, refer to the Medicare Claims Processing Manual, Chapter 12, 40.1. In the manual the CMS document says this "The global surgical package, also called global surgery, includes all the necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes the pre operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty." However, they go onto define Zero day global, and it clearly says NO pre-operative period and NO post-operative days, thus altering the previous sentence to merely mean "service furnished by a surgeon" the day of the procedure only.
Counterpoint #2:
A ZERO day global service having no postoperative period means you do not call the subsequent visits "Post-Operative". Any subsequent visit is an "Evaluation" visit and most likely an "Evaluation and Management" visit. The key point coding leaders are discussing in meetings I have attended, what did that doctor document from the perspective regarding "Managing" anything at that visit?
a) If a doctor sees a patient after they performed the amputation and billed either CPT 28820 or 28825, you should bill each "subsequent visit" separately as long as there was some form of E&M (evaluation and management) performed and documented. There are a myriad of management options that one would expect a doctor to state beyond the simple statement of "removal of sutures" . Some questions and answers to think about: Aren't you managing this patient's care beyond the amputation? Aren't you still managing their progress for healing? Are you discussing dressing changes needed, and/or any topical OTC medications prescribed for scar management, and/or prescription medication management, and/or discuss physical therapy, and/or shoe modifications and/or ambulation issues, and/or gradual and allowable return to normal activities. These are management concepts that should be addressed at these subsequent visits.
Fact: Prior to 1/1/2021 these two amputation codes each had 2 E&M CPT 99212 and 2 E&M CPT 99213 codes built into the reimbursement. Changing from a 90 day global to a 0 day global no longer included the 4 Post Operative E/M visits. This change lowered payment for these two services.
Conclusion: Everything comes down to documentation. The Chief Complaint should NOT read “Patient is seen for post-operative follow-up”, but rather a simple statement such as “Patient seen today for evaluation and management of previous amputation of ________ concerned of ______” This is because there is no allowance for post-op follow up with procedures having "0" global days. Also, simple cryptic one liners "sutures removed" are not in the doctors best interest to be considered as management. If you are managing the patient after evaluating them and following the new 2021 E&M Office Outpatient guidelines, then YES you should apply the appropriate level E&M at each encounter as CPT 99212-99215.
Sincerely,
David J. Freedman, DPM, FASPS, FACFAS CPC, CSFAC, CPMA
APMA, Chair Coding Committee
CAC-MD Representative
Certified Professional Coder
Certified Professional Medical Auditor
Certified Surgical Foot and Ankle Coder
Fellow, American Society of Podiatric Surgeons
Fellow, American College of Foot & Ankle Surgeons
Diplomate, American Board of Foot and Ankle Surgery, Certified in Foot Surgery
U.S. Foot and Ankle Specialists, LLC
Vice-President, Foot and Ankle Specialists of the Mid-Atlantic, LLC
Silver Spring/Leisure World Division/Office:
3801 International Drive, Suite 204
Silver Spring, Maryland 20906-1550
Tel: 301-598-0130
Fax:301-598-5091
Read Comments