The OIG looking for improper payments made on Evaluation and Management (E&M) services is nothing new. This year’s Work Plan includes several items on E&M services, including services made during the global surgical period. New to this year they will also be looking at the modifiers used on E&M services performed during the global period.
According to the Work Plan “Prior OIG work has shown that improper use of modifiers during the global surgery period resulted in inappropriate
payments. The global surgery payment includes a surgical service and related preoperative and postoperative
E/M services provided during the global surgery period.” CMS has establish a nation definition of the global surgical package for all Medicare carriers. The global period can be 000, 010, or 090 days and the package always includes:
- Preoperative Visits – Day before the surgery and day of the surgery are included unless the decision for surgery was made during the visit.
- Intra-operative services – Services that are a standard and necessary parts of the procedure.
- Complications Following Surgery – Any services during the postoperative period because of complications that don’t require a trip to the operating room
- Postoperative Visits – Follow-up visits during the global period related to recovery
- Postoperative Pain Management – if provided by the surgeon
- Supplies – unless identified as exclusions
- Miscellaneous Services – Such as wound care, or remove of sutures, casts, tubes, etc.
The OIG will be reviewing if certain modifiers used during the global period are being used correctly, which could include the -24, -25, and -57 modifiers. These are used to denote:
- 24 – Unrelated E&M service provide by the same physician during the global period
- 25 – Significant, separately identifiable E&M service provide by the same physician the day of a procedure that goes above and beyond the routine preoperative and postoperative care associated with the procedure
- 57 – The decision for surgery was made the day of or the day before a major surgery. This modifier is only to be used with procedure that have a 090 day global period as the desicion to perform minor procedures the same day is considered a routine preoperative service.
-24 modifiers on E&M services to bill for complications or -25 and -57 modifiers on standard preoperative care would result in the inappropriate payment that the OIG is looking for. Is your modifier usage compliant?