Adding a new service offering to your practice is exciting, whether it be OCT-A, imaging, CLIA-waived testing or a surgical procedure. As with any procedure or test, you must record medical necessity clearly if a third-party carrier will cover it. With surgical procedures, be aware of a few other medical record and coding compliance rules to ensure things are correct and to minimize any potential audit exposure.

Step 1: Minor or Major? 

First identify whether the procedure is considered minor or major. The length of the global period assigned to the procedure itself determines this designation.

Although the vast majority of surgical procedures that ODs perform are minor, there are some states that currently allow ODs to perform major surgical procedures. With the expansion of scope increasing across the country, I expect this trend to continue. 

Step 2: Code and Bill for the Office Visit 

Perhaps the most common mistake ODs make when billing a minor surgical procedure is billing an office visit on the same day as the minor procedure. To properly identify a legitimate office visit, you must use a modifier on the office visit. The National Correct Coding Initiative Policy Manual for Medicare Services defines how to determine the legitimacy of a visit and whether it is proper and recognized:¹

Minor procedures: If a procedure has a global period of zero or 10 days, it is defined as a minor surgical procedure. In general, E&M services on the same date-of-service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier -25. 

The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date-of-service as a minor surgical procedure.   

Major procedures: If a procedure has a global period of 90 days, it is defined as a major surgery. If an E&M is performed on the same date-of-service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier -57. Other preoperative E&M services on the same date-of-service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.

Step 3: Use Modifiers Properly

Modifiers describe a situation where the rules are sidestepped because the circumstances are exceptional. The key to using modifiers properly is making sure you follow the definition of the modifiers as described by the American Medical Association CPT Book, Appendix A.

 The primary modifier that ODs encounter with the greatest frequency is modifier -25. The improper use of modifier -25 is significant and has been the topic of many writings of the Office of Inspector General involving healthcare fraud, as many practitioners use it to get reimbursed for an improperly billed office visit.

Step 4: The Operative Report

From a medical record standpoint, surgical procedures require a separate narrative often referred to as an operative report. This typically describes the surgical procedure, preparation of the surgical field, instruments and approach used by the surgeon and a statement of patient status at the end of the surgical procedure. 

Incorporating surgical procedures into your practice is of great benefit to your patients, and knowing basic coding surgical procedures is essential to proper clinical standards.

Send questions and comments to rocodingconnection@gmail.com.

1. Centers for Medicare & Medicaid Services. National correct coding initiative edits. www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. Updated November 14, 2018. Accessed November 26, 2018.