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Procedures are commonplace in hospital medicine; more and more hospitalists have invested additional educational time in becoming proficient in performing them. Understanding the documentation requirements necessary to ensure proper payment of procedures, including adequate documentation of the medical necessity to perform them, is crucial. In addition, making sure that the Current Procedural Terminology (CPT) code is correctly linked to the proper International Classification of Diseases, 10th Revision (ICD-10) code(s) will further prevent claim denials.

Details regarding the service requirements of each procedure are outlined in the CPT Handbook, published by the American Medical Association. The Medicare Claims Processing Manuel discusses nuances in Medicare guidelines regarding situational and documentation requirements for reimbursement. Procedures may be described as “minor” or “major.” These terms have caused significant confusion in the literature. There are actually two different ways in which the terms “minor” and “major” procedures are used within the Medicare manual.


Surgeries and global packages

Within the Medicare Processing Manual, procedures are referred to as “surgeries” or “surgical procedures.” When discussing payment for the medically necessary care provided immediately before and after the procedure, one must be aware of the global period associated with the service. Services with global periods of 90 days are defined as “major surgeries” or “major procedures.” These terms are used interchangeably in the manual. Services with global periods of 0 or 10 days are described as “minor surgeries” or “minor procedures.” Endoscopies are included in this category. Most procedures performed by nonsurgical specialties fall into the “minor” procedure category.

One example of the importance of this distinction is use of modifier –57 (decision to perform surgery). Modifier –57 is only used when deciding to perform major and not minor procedures. Reimbursement for all care related to the surgery, by the surgeon performing the procedure, occurring 1 day before the procedure and for the ensuing 90-day global period, is bundled into the reimbursement for the surgery’s CPT code. One exception is the reimbursement for the E/M visit at which time the decision to operate is made if it occurs 1 day prior to surgery or on the day of surgery. Modifier –57 attached to that E/M code will allow for its reimbursement in addition to the reimbursement for the major procedure. For the situation where the decision to perform a minor procedure is made at an E/M visit the same day of the procedure, modifier –25 should be attached to that E/M code to show that it was medically necessary work, separate from the usual history and physical needed to safely perform the procedure.

Teaching physician procedural billing

With regard to teaching physician (TP) rules for procedural billing, a “minor” procedure is defined as taking <5 minutes to perform, and the ...

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