CMS Pub. 100-04, ch. 12, § 40.3

A. Relationship to Correct Coding Initiative (CCI)

The CCI policy and computer edits allow A/B MACs (B) to detect instances of fragmented

billing for certain intra-operative services and other services furnished on the same day as the

surgery that are considered to be components of the surgical procedure and, therefore, included

in the global surgical fee. When both correct coding and global surgery edits apply to the same

claim, A/B MACs (B) first apply the correct coding edits, then, apply the global surgery edits

to the correctly coded services.

B. Prepayment Edits to Detect Separate Billing of Services Included in the Global

Package

In addition to the correct coding edits, A/B MACs (B) must be capable of detecting certain

other services included in the payment for a major or minor surgery or for an endoscopy. On a

prepayment basis, A/B MACs (B) identify the services that meet the following conditions:

• Preoperative services that are submitted on the same claim or on a subsequent claim as

a surgical procedure; or

• Same day or postoperative services that are submitted on the same claim or on a

subsequent claim as a surgical procedure or endoscopy;

and -

• Services that were furnished within the prescribed global period of the surgical

procedure;

• Services that are billed without modifier “-78,” “-79,” “-24,” “25,” or “-57” or are

billed with modifier “-24” but without the required documentation; and

• Services that are billed with the same provider or group number as the surgical

procedure or endoscopy. Also, edit for any visits billed separately during the

postoperative period without modifier “-24” by a physician who billed for the

postoperative care only with modifier “-55.”

A/B MACs (B) use the following evaluation and management codes in establishing edits for

visits included in the global package. CPT codes 99241, 99242, 99243, 99244, 99245, 99251,

99252, 99253, 99254, 99255, 99271, 99272, 99273, 99274, and 99275 have been transferred

from the excluded category and are now included in the global surgery edits.

Evaluation and Management Codes for A/B MAC (B) Edits

92012 92014 99211 99212 99213 99214

99215 99217 99218 99219 99220 99221

99222 99223 99231 99232 99233 99234

99235 99236 99238 99239 99241 99242

99243 99244 99245 99251 99252 99253

99254 99255 99261 99262 99263 99271

99272 99273 99274 99275 99291 99292

99301 99302 99303 99311 99312 99313

99315 99316 99331 99332 99333 99347

99348 99349 99350

99374 99375 99377 99378

NOTE: In order for the services of CPT codes 99291 or 99292 to be paid during the

preoperative or postoperative period, the critical care service must be unrelated to the

procedure. In these situations, the physician must append the modifier -FT ((unrelated

evaluation and management (E/M) visit on the same day as another E/M visit or during a

global procedure (preoperative, postoperative period, or on the same day as the procedure, as

applicable). (Report when an E/M visit is furnished within the global period but is unrelated, or

when one or more additional E/M visits furnished on the same day are unrelated.))

See section 30.6.12.7 of this chapter for further discussion of critical care visits unrelated to the

procedure with a global surgical period.

If a surgeon is admitting a patient to a nursing facility for a condition not related to the global

surgical procedure, the physician should bill for the nursing facility admission and care with a

“-24” modifier and appropriate documentation. If a surgeon is admitting a patient to a nursing

facility and the patient’s admission to that facility relates to the global surgical procedure, the

nursing facility admission and any services related to the global surgical procedure are

included in the global surgery fee.

C. Exclusions from Prepayment Edits

A/B MACs (B) exclude the following services from the prepayment audit process and allow

separate payment if all usual requirements are met:

Services listed in §40.1.B; and

Services billed with the modifier “-25,” “-57,” “-58,” “-78,” or “-79.”

Exceptions

See §§40.2.A.8, 40.2.A.9, and 40.4.A for instances where prepayment review is required for

modifier “-25.” In addition, prepayment review is necessary for CPT codes 90935, 90937,

90945, and 90947 when a visit and modifier “-25” are billed with these services.

Exclude the following codes from the prepayment edits required in §40.3.B.

92002 92004 99201 99202 99203 99204

99205 99281 99282 99283 99284 99285

99321 99322 99323 99341 99342 99343

99344 99345