Key Takeaways
- The surgical package (global period) includes the procedure itself, local/topical anesthesia, immediate postoperative care, typical follow-up care within the global period, and writing of orders.
- Major surgical procedures have a 90-day global period; minor procedures have a 0-day or 10-day global period.
- Modifier -25 is appended to an E/M service to indicate a significant, separately identifiable evaluation on the same day as a minor procedure.
- Modifier -59 indicates a distinct procedural service to bypass NCCI (National Correct Coding Initiative) edits when procedures are not typically reported together.
- Modifier -51 indicates multiple procedures performed during the same operative session by the same provider.
- Modifier -26 indicates the professional component only (interpretation/report), while modifier -TC indicates the technical component only (equipment/technician).
- Separate procedure designation in CPT means the procedure is integral to a more comprehensive procedure and should not be reported separately when performed as part of the larger procedure.
- Surgical modifiers -LT (left side) and -RT (right side) identify laterality, while -50 indicates a bilateral procedure.
Surgical Coding Guidelines & Modifiers
Surgical coding is the largest CPT section and accounts for approximately 30% of the CPC exam. Understanding the global surgical package, proper modifier usage, and surgical coding conventions is essential for accurate code assignment.
The Global Surgical Package
When a surgeon performs a procedure, payment includes not just the surgery itself but a bundle of related services called the global surgical package:
What Is INCLUDED in the Global Package
| Component | Description |
|---|---|
| Pre-operative services | E/M on the day of or day before surgery (when decision for surgery has already been made) |
| Intra-operative services | The procedure, local/topical/digital anesthesia, routine supplies |
| Post-operative services | Typical follow-up care within the global period |
| Complications | Treatment of complications that do not require return to the OR |
| Writing orders | Post-surgical orders, prescriptions |
| Dressing changes | Routine wound care |
What Is NOT INCLUDED (Separately Reportable)
| Service | When Separately Reportable |
|---|---|
| Significant, separately identifiable E/M | When a separate E/M service beyond the decision for surgery is provided (modifier -25 or -57) |
| Unrelated E/M during global period | E/M for a condition unrelated to the surgery (modifier -24) |
| Return to OR for related procedure | Additional surgery during global period related to the original procedure (modifier -78) |
| Unrelated procedure during global period | A procedure unrelated to the original surgery (modifier -79) |
| Staged/planned procedure | A planned additional procedure (modifier -58) |
Global Periods
| Period | Description | Example Procedures |
|---|---|---|
| 0-day | No post-op period; E/M next day is separately reportable | Minor procedures (some skin biopsies, injections) |
| 10-day | Follow-up included for 10 days post-procedure | Minor surgical procedures (lesion removals, I&D) |
| 90-day | Follow-up included for 90 days post-procedure | Major surgical procedures (joint replacement, organ surgery) |
Essential CPT Modifiers for Surgery
Modifier -25: Significant, Separately Identifiable E/M
Purpose: Appended to an E/M code when a significant and separately identifiable E/M service is performed on the same day as a minor procedure (0-day or 10-day global period).
Example: A patient comes in for a scheduled mole removal (minor procedure). During the visit, the physician also evaluates the patient for new-onset headaches and orders imaging. The E/M for the headache evaluation is separately reportable with modifier -25.
Key Rules:
- Only appended to the E/M code, never to the procedure code
- The E/M must be beyond what is typical for the procedure
- NOT used with major surgeries (use modifier -57 instead for the decision for surgery E/M)
Modifier -57: Decision for Surgery
Purpose: Appended to the E/M code when the decision to perform a major surgery (90-day global period) is made during that E/M visit.
Example: A patient presents with abdominal pain, and the physician evaluates and determines the patient needs an appendectomy. The E/M visit where this decision was made is reported with modifier -57.
Modifier -59: Distinct Procedural Service
Purpose: Identifies a procedure or service that is distinct from other services performed on the same day, used to bypass NCCI edits that would normally bundle the procedures together.
Criteria for -59: The procedures must be:
- Different anatomical site or organ system, OR
- Different encounter/session, OR
- Different incision/excision, OR
- Separate lesion or injury
CMS X{EPSU} Modifiers (more specific alternatives to -59):
| Modifier | Meaning |
|---|---|
| -XE | Separate encounter |
| -XP | Separate practitioner |
| -XS | Separate structure |
| -XU | Unusual non-overlapping service |
Modifier -51: Multiple Procedures
Purpose: Indicates that multiple procedures were performed during the same operative session by the same provider.
Key Rules:
- Appended to the secondary (additional) procedure codes, not the primary procedure
- The highest-valued (most complex) procedure is listed first without modifier -51
- Many payers reduce payment for procedures reported with -51 (typically 50% of the second procedure, 25% of additional)
- Add-on codes (+) are exempt from -51 — do NOT append -51 to add-on codes
Modifier -26 and -TC: Component Billing
| Modifier | Component | Who Bills | What's Included |
|---|---|---|---|
| -26 | Professional component | Physician/provider | Interpretation, report, clinical judgment |
| -TC | Technical component | Facility/lab | Equipment, supplies, technician |
| No modifier | Global service | One entity does both | Both professional and technical components |
Example: A radiologist at an independent practice interprets a chest X-ray performed at a hospital. The hospital bills the technical component (equipment, technician) and the radiologist bills with modifier -26 for the professional interpretation.
Modifier -52 and -53: Reduced and Discontinued Services
| Modifier | Meaning | Example |
|---|---|---|
| -52 | Reduced services | Planned bilateral procedure, only one side performed by physician choice |
| -53 | Discontinued procedure | Procedure started but stopped due to patient safety concerns |
Laterality Modifiers
| Modifier | Meaning |
|---|---|
| -RT | Right side |
| -LT | Left side |
| -50 | Bilateral procedure |
Separate Procedure Designation
In CPT, procedures labeled as (separate procedure) are those that are:
- Commonly performed as an integral part of a larger, more comprehensive procedure
- Should NOT be reported separately when performed during the same session as the comprehensive procedure
However, if the separate procedure is performed:
- At a different anatomical site, OR
- Through a different incision/approach, OR
- For a different diagnosis/condition
...then it MAY be reported separately with modifier -59 (or the appropriate X{EPSU} modifier).
Example: Lysis of adhesions (labeled "separate procedure") performed during an abdominal surgery would NOT be separately reported. But lysis of adhesions at a completely different anatomical site during a separate portion of the session might qualify for separate reporting with modifier -59.
Surgical Coding: Key Body System Notes
Integumentary System
- Wound repair: Lengths of same complexity and anatomical group are added together before code selection
- Lesion excision: Measured by the excised diameter (lesion + narrowest margins), not the defect size
- Excision codes are divided by benign vs. malignant and anatomical site
Musculoskeletal System
- Fracture treatment: Open (ORIF) vs. closed reduction — different code ranges
- Arthroscopy: Diagnostic arthroscopy is included in a surgical arthroscopy of the same joint
- The most complex procedure in a joint is listed first
Cardiovascular System
- Cardiac catheterization: Coded by approach (right heart, left heart, or combined) and whether coronary angiography is included
- Coronary interventions: Coded per vessel (PTCA/stent placement coded per vessel)
- Pacemaker/ICD: Separate codes for generator and leads; insertion vs. replacement
A patient comes to the office for a scheduled skin lesion excision (10-day global). During the visit, the physician also evaluates a new complaint of persistent cough and orders a chest X-ray. How should the E/M for the cough evaluation be reported?
A surgeon performs three procedures during the same operative session. How should the procedures be sequenced and modified?
Which modifier is used to report the physician's interpretation of a diagnostic imaging study when the equipment and technician are provided by a separate facility?
A procedure is started under general anesthesia, but the patient develops cardiac arrhythmia and the surgeon discontinues the procedure for patient safety. Which modifier should be appended?
Match each CPT modifier to its correct description:
Match each item on the left with the correct item on the right
When reporting multiple surgical procedures from the same operative session, arrange the coding steps in the correct order:
Arrange the items in the correct order
Wound repair coding requires adding together the lengths of repairs. Which repairs can be added together?
A major surgical procedure has a ___-day global period during which routine follow-up care is included in the surgical package.
Type your answer below