July 5, 2024
By: Mary A Curry, BS, CPC, CPMA
Auditing the Global Package
When auditing provider services, what is the best method to approach the concept of a global package? Some rental companies provide a renter with all-inclusive pricing for an apartment. The payment arrangement covers heating, electricity, water, and garbage for the one-bedroom apartment. Anything outside of these restrictions incurs separate expenses, such as internet service. This concept is how Medicare and Medicaid Services (CMS) and many other payers have applied a single payment for surgical procedures with a 10- or 90-day global period.
Only physicians paid under the Medicare Physician Fee Schedule are eligible for a global surgical package, also known as global surgery. This package includes all necessary pre-, during-, and post-operative services typically provided by a surgeon. Reimbursement for a surgical procedure encompasses the services provided by the surgeon or other specialists within the same group, both before, during, and after the operation.
The medical coding post-operative audit should incorporate the following key elements:
- Identifying whether the surgeon will be providing the global surgical package is essential.
- If the surgeon only provides a portion of the global surgical package, ensure the patient’s medical records contain a copy of the signed transfer agreement and the appropriate modifiers are attached to the CPT code(s).
- Confirm that the patient’s demographic information is correct and matches the medical records.
- Verify that the operative report is complete and that the report body appropriately supports the assigned procedure code(s).
- Verify that the documentation supports the procedure’s medical necessity (s).
- Verify that all CPT and ICD-10 codes accurately and correctly reflect the patient’s diagnosis and surgical reason.
- Verify that the appropriate modifiers are given to CPT codes to reflect the aspects of the procedure (e.g., laterality, multiple procedures, unplanned return to OR, and staged procedures).
- Verify that payer-specific rules and policies have been followed.
- If relevant, the Teaching Physician Guidelines were followed.
- Verify that internal standards and processes have been followed.
- Verify whether the patient’s medical records contain documentation of post-operative care, such as follow-up visits and any complications.
- Examine the explanation of benefits (EOBs) and remittance advice to ensure correct reimbursement and detect anomalies.
- Prepare a report on the audit findings, including any errors or discrepancies and recommendations for corrective action plans.
- Set a date for a follow-up audit
- Provide remarks to the surgeon and the coding team on any discrepancies or areas for improvement. Offering education and training could help avoid future discrepancies.
Conducting a post-operative coding audit allows you, as the auditor, to contribute to improving the organization’s coding and billing processes, assure compliance with regulatory requirements, and ultimately improve patient care and avoid future damage to the bottom line.
Resources:
MLN907166 December 2023: Global Surgery MLN Booklet
CMS Medicare Chapter 12 Claims Processing Manual
Surgical services require auditors and coders with expertise in the specialty area. The NAMAS Team has the skills to support coding, auditing, and coding validation projects for any surgical specialty, including adult and pediatric medicine.
