Billing CHP or consult
Can I bill an H&P or consultation on the same day that I perform a procedure?
Yes, as long as you are the surgeon who is providing an initial evaluation or consultation in which the decision to operate is made. In this scenario, the H&P or consultation is not included in the surgical package and will be paid separately.
Criteria:
- You are the admitting or consulting physician seeing the patient for the first time (performing an initial evaluation or consultation); and
- You are making the ultimate decision to perform the procedure the day of the procedure.
Do I need to append a modifer to the CHP or consultation when the above criteria is met?
Yes, you must append a modifier 25 or 57 to the H&P or consult code. Do not append the modifier to the procedure code. If you do not append the modifier, the insurance carrier will consider your H&P or consult included in the payment for the procedure (surgical package).
Modifier 25 – for minor procedures
- Diagnotic Catherization
- Coronary Interventions
- TTE
- TEE
- Echo
- PET
- Holter Monitor
- Colonoscopy
- Flex Sig
- Esophagoscopy
- EGD
- ERCP
- Pulmonary Bronchoscopy
Modifier 57 – for major procedures
- Insert/Replace perm pacer
- Insert/Replace generator
- Upgrade single to dual
- Reposition previous PM or ICD electrode
- Insert electrode
- Repair electrode
- Revision/Relocation of pocket
- Revision of pocket for ICD
- Remove perm pulse generator
- Remove lead
- Insert/Replace pulse generator only
- Removal of pulse generator, only
- Removal of leads-nonthoracotomy
- Insert/Replace leads & ICD nonthoracotomy
- Loop recorder implant
- Removal of loop
What does Medicare consider “part of the surgical package?”
Medicare and other carriers consider payment for the procedure to include the following:
“Surgical Package”
- Pre-op = History, exam and medical decision making
Local infiltration, digital block, topical anesthesia - Surgery = Operation
- Post-Op = Normal, uncomplicated follow-up care
( Varies depending on if the procedure is major or minor; see below)
What is a major and a minor procedure?
Major procedures are differentiated from minor procedures by the number of global days assigned to the procedure (see below). Any services that are provided within this global period are considered included in the payment for that procedure.
Major procedure = 90-day global period:
- One day before surgery
- One day of surgery
- 90 days after surgery (normal, uncomplicated follow-up care)
Minor Procedure = 0-to 10-day global period:
- 0-day global: day of surgery only
- 10-day global: 1 day of surgery
- 10 days after surgery
Can I bill for follow-up care after I perform a major procedure (90-day global)?
Any related follow-up care provided within 90 days following the procedure is considered included in the payment for the original procedure (surgical package). Exception: You can bill for follow-up care if it is unrelated to the procedure. A different diagnosis must be used to illustrate that the follow-up care was unrelated to the procedure.
Can I bill for follow-up care after I perform a minor procedure (0 to 10-day global)?
Minor procedures with zero-day global – all follow-up care is not included in the payment for the procedure and it can be billed separately.
Minor procedure with 10 day global – Any related follow-up care provided within 10 days following the procedure is considered included in the payment for the original procedure (surgical package). Exception: You can bill for follow-up care if it is unrelated to the procedure. A different diagnosis must be used to illustrate that the follow-up care was unrelated to the procedure.
