Hello, everyone and welcome to day 2 of our boot camp. I'm going to wait about a minute or 2 to let people get logged on. And, but we'll get started shortly. Hello again, if you're just joining us, we will get started pretty quick. We're just going to give people some time. There's a large group that is signed up for this one today, so we want to make sure everyone has time to log on before we get going. All right. Well, again, welcome to day two of our boot camp. Today, we're going to discuss modifiers, the global surgery package, and then some documentation tips in CV. My name is Jolene Bruder. I'm the Manager of Surgery Coding with Revenue Cycle Solutions. Thankfully, I'm joined today by our Director of Coding, Jamie Quimby. She and I haven't actually got to do a webcast together in a while, so we're excited to be tag-teaming this one today. So before we get started, as always, we have our housekeeping. On the chat button here, this is where you can click to get the link for the slides. I know some of you have issues with that, and you can reach out to our technical team in the chat box, and they will help you with that. Then our other button is the Q&A, and that is where you will send questions for the presenters. We ask that you do not put questions in the chat because we don't monitor those. We do want them in the question box. As always, we do ask that you keep your questions on topic, and we will answer as many as we can at the end of the presentation. For those of you that were on yesterday, I did let everyone know, we will be combining all the questions and get those answered for all of the bootcamps this week, but we probably will not get all of that out until mid-January. Again, with the amount of questions with each bootcamp, it takes a while for our team to sift through all of that. Next, this is for the coding CEU certificates. You can obtain them from the Academy. You'll download in the transcript section of your account. We do ask that you allow one to two business days for our team to get those uploaded, and you can access them. Again, this is just a screenshot to show you where you can claim your CEU, and you can either download it, print it, whatever you want to do with that, and then upload that to your AAPC account. The first thing we're going to cover is the Global Surgery Package. With this, basically, the Global Surgery Package sets up uniform payment policies for Medicare, and it allows claims to be processed correctly. It addresses bilateral procedures, multiple surgeries, co-surgeons, team surgeons, and basically, it lets you know what is included in that package, and then things that are separately billable. There is a new one out this year. It was revised in November of this year, actually, so you can Google the MLN. I do have the link in here also, but you can Google that, and that will give you the most up-to-date surgery package, the Global Surgery Package, and there is a wealth of information in that, and we highly recommend that you keep the current copy with you. So, the surgery settings for that global surgery are inpatient, outpatient, ambulatory, and then also, it addresses physician office. And some of the classifications of the global surgery. So, we have our zero-day post-op, which is mainly going to be your endoscopies, some minor procedures, your caths, interventions. Tabbers actually fall under the zero-day post-op. So, basically, what that means is the visit on the day of procedure is normally not payable unless, like, if you take, for example, if you come through ER and you have chest pains and they take you to the cath lab and you have an intervention performed in a cath, and that decision, I don't like to use the word decision, but that E&M encounter leads to going to that cath lab, then you can put a modifier on that, and we'll get into the specific modifiers, obviously, later in the presentation. But just note, you do not bill for elective procedures where that has already been, you know, decided. If they've come in the office and they schedule this cath a couple weeks out, you can't then turn around and bill for another E&M visit for that same day. For 10-day post-op, there actually is no preoperative period, but, again, the visit on the day of procedure is not payable unless it's the same type of scenario I just talked about. But our total global days with the 10-day is actually 11 because you count the day of the procedure and then 10 days after. For 90-day global, it actually does include one day preoperative, day of procedure as well, and then our total global period for that is 92 days. So you have the day prior, the day of, and then 90 days after. Now, the 90-day global is when you, if they have that E&M the day of or day prior, because, again, you have an emergent-type situation, then you use those 57 modifiers. And, again, I'll go over that more in depth. But right here is that link to that MLN article that gives you the global surgery information. And, as I said, it was revised in November of this year. So the Medicare fee schedule is where you can find out what type of global your procedures fall under. So those with the zero, that's, again, your endoscopies, your minor surgical procedures, your caths, TAVRs, things such as that. Then you have other minor procedures that have a 10-day global. One of the things I can think of right off the top of my head would be STAB phlebectomies in the vascular surgery realm where they go in, those have a 10-day global. Your tunneled central lines have a 10-day global. And then, of course, we have our major surgeries with the 90-day global. Codes YYY, that actually is the Medicare carrier will decide. Those are those contractor-priced codes. And the max will decide if it's going to be a zero, a 10-day, or a 90-day. The ZZZ code is for add-on codes. And those are, they don't have a separate global code. They just fall with whatever the primary service is. And then procedures with the XXX, that means the global concept does not apply. So let's talk about some of the services that are included in the global package. So again, we have that pre-op visit for our 90 days. That does not apply to your zero-day global or your 10-day global. That's only the 90-day global. Post-op would be with your zero-day. That'd be the day of. Or in the case of 10-day or 90-day, those are the visits that are included. And the reason why those are included, especially for those of you that are new to some of this, basically, when they set the RVU for a procedure, especially with a 90-day, so let's take a CABG, for instance, they build into that procedure code and that RVU pre-op visit, so many post-op visits and critical care visits and things of that nature. So that's why that's already included in that package and the surgeon's already being paid for that. So that's why, you know, when you have those decision for surgery days that that is separately billable because of that situation, but normally, if it's an elective, that's already built in. So that's why they don't allow it. Same with your post-op visits. If it's anything related to that surgery, you cannot bill for it. It would have to be a new problem. Also included in the global package are intraoperative services that are necessary part of the procedure. So for example, this would be the incision. We don't bill separately for opening the patient up. We also don't bill separately for closing them. Any post-surgical pain management, so your Q pumps, things like that, that's all included. Other medical or surgical services that the surgeon provides during the post-op period, and the exception to that would be a return to OR. So let's say they end up doing a bedside and they add a chest tube. That would be included. Now, if they took the patient back to the OR for a chest tube, which that would be rare, but let's say they have to end up doing a tracheostomy, something to that nature, or the patient starts bleeding. Well, once they're taken back to the OR, then that can be billed and there's modifiers for that. And again, we'll get into all that. And then kind of the catch-all is the supplies that are involved with the surgeries and that. Those are also included. So some of the, and then we have the final catch-all, which is your miscellaneous. So that includes your dressing changes, incision care, operative pack removal, suture, staple removal, urinary caths, tracheostomy tubes that are changed if they don't return to the OR, chest tubes, lines, wires, drains, art lines, things of that nature, that's all included. Your nasal gastric, rectal tubes, anything like that. Those are those miscellaneous services that are included and not separately billable unless you meet a certain requirement. Again, if they have to go back to the OR, then that would be a different scenario. So some of the things that are not included, excuse me one second. Sorry about that. So one of the things is that surgeon's first determination of that need for surgery. Now keep in mind, I've seen this happen. If it's an elective surgery and it's not being done, the surgery's not being done that day or the next day, you don't need to put a 57 modifier on those E&M services. So if they know they're going to have to do a valve replacement on a patient and they bring them in and they determine they're going to do surgery and they set that up for later, then you don't need to put a 57 on that. So please keep that in mind. I'm so sorry. Okay, so other providers that are related to surgery services except one done of a transfer of care, that's not included. Visits unrelated to the surgical diagnosis. Underlying condition or an added treatment course that's not normal surgery recovery. Diagnostic tests and procedures. That includes radiological procedures. Those are not included in the global surgery package. And then distinct surgical procedures. All right, distinct surgical procedures that aren't part of reoperations. Also, treatment for post-op where they do return to the OR, that's separately billable. A less extensive procedure fails and a more extensive procedure is done, that can be billed. Organ transplant, immunosuppressive therapy, and then critical care services that are unrelated to the surgery, and you will add the FT modifier. Jamie's going to cover that more in depth. So for multiple surgeries, we have a single provider or providers in the same group, on same patient, same day, separate payment is allowed. Co-surgeons, surgical teams, or assistants. Surgery subject to multiple surgery with an indicator of two, and two or more providers that each do distinctly different unrelated surgeries on the same patient, same day. Those do not fall under multiple surgery payment. All right, post-op period. These are the states that are required to report the 99024. So we have Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island. You are exempt from this if you have less than 10 practitioners, but you're still encouraged to report. For the rest of you that live in the other states, we still recommend that you do report them, but just note this group, if you have more than 10 practitioners, you have to report. You have to report those global services. And again, this would be providers who provide the entire global package. They will report their CPT procedure code, and then all the separate visits that are allowed, or that are included, or part of that global package are not separately billable. Different providers in a group practice that take part in the patient's care, the group practice bills the entire global package. And then providers who are part of a global surgical package, more than one provider can provide services, but keep in mind, so if you have three CT surgeons, one of them performs a surgery, and maybe the other two do some post-op follow-up with that patient, that's, you know, you're all considered one, the same provider. So all of that specialty falls under that global surgery package. Same with EP. If the EP providers do an AICD, they own that global, everybody that's in that group, that's an EP provider. Now, your interventionist, if they're treating CAD, let's go back to that CT surgeon, if they're treating the CAD disease, they can bill, they do not have to use modifiers. Now, that is with Medicare. Some of your commercials, you may have to fight that point, but keep that in mind, that it's the specialty that provides the surgical package, they're the ones that own that global. So your heart failure doctors don't own a CT surgery global, nor do they own an EP global. Same with, like I just said, with the interventionist, so keep that in mind. But the other thing I want to talk about with this, so more than one provider provides services in a global surgical package, you have providers perform the surgical procedure, but for whatever reason, if they can't provide the follow-up care, then these providers can agree on a transfer of care. And again, I'll talk about this more in depth with the actual modifiers. Oh, I've been fighting this since Thanksgiving. All right. If more than one provider provides services in the global service package, providers approve the sum. They cannot exceed what CMS would pay if a single provider provides that service. So you have one surgeon performs a surgery and then another provides the pre-op, post-op. That joint payment cannot exceed the global amount. And then we have the scenario where we have a surgeon and provider providing the post-op care. If they do that formal transfer, they have to keep a written agreement in the patient's medical record. Okay, so let's get into the modifiers. So you need to know when to use a modifier. Ensure you're using the right modifier and then ensure you're using them appropriately, not just to get your claim paid. So you always have to make sure you've met the medical necessity and the documentation supports that. So modifiers reported on item 24d on the CMS 1500. Payment modifiers should always be reported in the first position. I'm not going to read them all off. I'm trying to save my voice so you can see and hear which ones are the payment modifiers. Informational modifiers fall into the second, third, or fourth field depending on how many modifiers you're reporting. They do not affect reimbursement. And if you're only entering informational, the order doesn't matter. So for modifier 50, CPT coding recommends a single line entry with a modifier 50 to indicate that you have a bilateral service, which means the surgery is performed on both sides of the body at the same operative session or the same day. One of the easiest examples I could give you would be a lobectomy of a lung, one on the right and one on the left. That would be considered a bilateral service. Modifier 50 is allowable and it is reimbursed at 150% of the Medicare fee schedule. Note modifier 50 does not apply to ASC. So ambulatory surgery centers do not report the modifier. They would report each CPT code twice. 51 modifier is multiple procedures, same day, same session, same position, same patient. Keep in mind, not everyone has to report this. If you are not required to report it, do not report it because if your Medicare carrier already does it and you add a 51, they'll reduce it twice. So you don't want that. You never use it on an add-on code. You never use it on your primary code. And then the reduction is actually determined by the Medicare fee schedule approved amount. And then pricing indicators do affect surgical procedures. You have your endoscopy rules, which means, you know, your endoscopy, when those are done, your first procedure is paid at 100% and then the second one is 50. And then third and so on are reduced to 25%. So keep that in mind. All right. So now let's talk about this modifier 54, 55, and 56. So 54 is surgical care only. And that shows that the surgeon gave all or part of the post-op care to another provider. It does not apply to the assistant. It does not apply to ASC facility fees. And it is used if there's a formal transfer of care or an informal. So it doesn't have to be, you know, it doesn't have to be a formal transfer. It can be informal, but it is non-documented on the informal, but that there is an expected transfer of care. For modifier 55, this is used with CPT procedures that have a 10 or 90 day global. Date of surgery is the service date and shows the date the patient transferred to another provider. So for 55, this is, does require that there is a transfer agreement in the record. The accepting provider must provide one service before billing any part of the post-op care. And again, the modifier does not apply to assistant at surgery or the ASC facility. 56 is for pre-op care only, and that would be require a formal transfer of care. So again, I brought this up yesterday. These aren't used that often. And it would be, you know, like one of the examples would be you're out of state, you have a surgery, and then you go back home and you go to a local surgeon to take care of you on your follow-up because, you know, I mean, let's face it, depending on how sick you are, I mean, you're probably not going to want to spend 90 days away from your house to have all of your post-op care delivered to you. Now, there are some exceptions. If the transfer of care doesn't happen, then you report occasional post-discharge provider services other than the surgeon using the E&M code, and you don't need any claim modifiers. For 2025, we do have this new add-on code. The G0559, and this is for post-operative care services provided by a practitioner other than the one who did the surgical procedure. This is an add-on code, and it shows time and resources involved in the post-op follow-up visits. Keep in mind, this is not for, like I came from, from a post-op follow-up visit. Like, I came from a group where we had cardiologists, we had CT surgeons, we had vascular surgeons. This code would not apply in those situations because they're all part of the same group. It would have to be a totally separate group. So, if, you know, a group of surgeons belong to HCA and then a group of cardiologists that belong to, you know, OSF Catholic hospitals and the HCA doctors did the surgery, and the OSF group of cardiologists is doing the post-op, that's when you would use this. This has nothing to do with taxonomy codes, and it has nothing to do with anybody in the same group. So, you'd have to be a totally separate group. All right. Next, we have the modifier 57. Again, that's for decision for surgery, and that would be applied on a day prior or the day of a global procedure. So, again, you're not going to use it if the decision was made a couple of weeks prior. You do add that 57 modifier to the appropriate level of your E&M service, and you do not use it on a minor procedure. So, this would be 90-day global only. An example of appropriate use, the patient admitted for following cardiac cath, where it was recommended the patient see a CT surgeon. Surgeon sees the patient, makes the decision that the patient needs surgery. Patient's then scheduled for the CABG the following day. So, we would put that 57 on that E&M service for that day, because the next day we're going to do that CABG. Now, in the event something happens, and they don't do that surgery that next day, then you wouldn't need the 57. If they end up, you know, something happens, a patient isn't stable, and they wait three or four days to perform that surgery, then you would not need to put that 57. Keep in mind, though, because I see this happen, if there has been that lag of a few days, do not report the E&M the same day and try to use that decision for surgery again, because that's already been made. Once it's been made, it's been made, and there's no way around it. So, don't push the envelope on that. Again, inappropriate use would be, you know, obviously, we already talked about, patient was seen, this is an elective surgery, and now they're admitted to the hospital, and the physician dictates an H&P to satisfy the hospital, you're not going to use a 57, and then also you're not going to use that 57 if you're not the provider that's going to own that global. So, again, if a patient sees an interventional cardiologist the same day of an AICD implant to evaluate a patient's coronary artery disease, they do not use a 57 for that. They shouldn't need any modifier. Again, though, some of your commercials do a little bit of different rules, so you have to follow what they want you to follow. Modifier 24. So, this is unrelated E&M during post-op visit. So, this would be a service that's provided within that post-op time frame, but it's unrelated to the procedure, the original procedure. So, a good example of this, again, let's say we do a CABG on a patient, and when they do that CABG, later on, or maybe during that 90-day global, they find out the patient has a spot on their lung, and now they're going to, you know, see the patient for that, then you would add that 24 modifier. You could actually have even a 24 and a 57 on the same claim if they end up doing surgery the next day or day of for that lung procedure. So, keep that in mind. And note, 224 only goes on E&M services. They should never be put on any procedure CPT codes. And here we have a patient presents an office for CAD and hypertension. He had a pacer implanted three weeks ago. Patient complains of severe chest tightness for the past two days. It's relieved with rest and nitro. Patient also complains of nausea. So, in this above example, although the patient had that pacemaker placed three weeks ago, and they're in that 90-day global, they're not being seen for that pacemaker. This is something new. Now, more than likely, your EP doc would, if it is an EP doc, would transfer that in this patient to go see an interventionalist. But note that, you know, this patient comes in, and they're complaining of something new, then that is, that's not related to that original patient. Then that is, that's not related to that original procedure, then you can bill that. Again, if it is a service that's related, then you do not use the 24. And then again, if the patient's in a global and sees a cardiologist from the same practice for congestive heart failure, you're not going to use a 24 because that global belongs to the cardiologist. Now, I know some of you are probably going to say, hey, we run into this a lot, or we'll get denials. My first piece of advice on that, go back and make sure your heart failure providers, your interventionalists have the correct taxonomy code attached to them. Because the cardiologist should not, you should not be seeing denials for a global period for a CT surgeon, or a vascular surgeon, or an EP, with your regular cardiologist, your heart failure, and your interventionalist. And then I definitely, you would want those to be appealed. So, next we'll talk about modifier 58. That's staged or related procedure by the same physician during the post-op period. It's planned or staged, and then a new post-op period will actually start. So, some of the, a good example of this for the most of our population of our membership would be, if they do aortic valvuloplasty, and then they do the TAVR, well, within 90 days, because the valvuloplasty has that 90-day global, the TAVR itself does not. But once you're going to go perform that TAVR, you're going to want to put a 58 modifier on it, because otherwise it would be reduced. You certainly don't want to use a 78, because the TAVR is actually a more extensive procedure than that valvuloplasty. So, keep that in mind. But that's one of the best examples. If they do that aortic valvuloplasty, and within that 90-day period, they then implant the TAVR, you're going to want the 58 on the TAVR. Some of your... Jolene, sorry. I have a good example for this scenario, too, for all of our EP coders. So, and I see this scenario a lot. So, a lot of times a provider will put a pacemaker implant in with a planned AV notablation later to try to control that patient's AFib. So, as you know, the 90-day global will apply for that pacemaker implant, but sometimes two weeks later, they're bringing the patient back into the hospital as an outpatient to have that AV notablation done so that they can control the AFib by putting the patient in that complete heart block, which will make them pacemaker dependent. So, on your AV notablation that's done later, that is a perfect example where you would append the modifier 58, because it was a known procedure that the provider was going to do after the implant. Awesome. Great example. Thanks, Jamie. All right. So, for modifier 78, this one is unplanned return to the OR for a related procedure. Easiest example of this is a patient develops, they start bleeding, or they get infection, and they have to go back. And, you know, again, usually we're talking cabbages, valves, lungs, anything like that can be your vascular surgeons as well. And not to say that it couldn't happen with pacers or AICDs. But one thing about this, again, it's related. It is during that 90-day post-op time frame, and or even could be the 10-day. Keep in mind, though, if I see this a lot, especially with the bleeding, if the patient is bleeding profusely, and they do not have time to get that patient to the OR, your providers need to document that, you know, due to the fact they're bleeding, and it was emergent, and they did that at bedside, you can bill that, you know, that it's the 35820 if you're talking about the chest. You can bill that with a 78 modifier as a bedside procedure, because of it being emergent. But again, your providers need to clearly document that. This does not reset the global, excuse me, All right, 79 is unrelated during a post-op by the same provider. A new post-op period begins, and this is something new. So this again would be like your CABG, and now they're doing a lung procedure. So this is a scenario where you could use that 79. Or if you have carotid, and they do the right side, and then they bring them back in within 90 days and do the other side, then that would be 79 because that's actually unrelated. You wouldn't use a 58. This is unrelated because you're on a different side of the body. forgot to unmute. um so again we have that modifier 58 i show i already talked about the taver example on the um 78 patient hemorrhage 79 they do a mitral valve repair and then come back and do an upper lobe wedge resection something to that effect. for assistant in surgery um they do pay 16 percent of the applicable surgical payment we have modifiers 80 81 81 82 and as um that are used to report these keep in mind some procedures allow assistant no matter what others only allow if the documentation supports the need so in those situations um your provider has to give a medical reason a necessity as to why they needed an assistant again a good example of that would be a carotid stent um an 80 is allowed with a carotid stent but it's not just an automatic so there has to be some reason so maybe the patient's very obese maybe they encountered a lot of um difficulty getting uh access uh to the carotid whatever the case may be that has to be documented the other thing no matter what whether the procedure allows it or allows with documentation you also have to document what the assistant did it's not enough to list them they do have to state what they did something else that we've been running into lately here at med axiom was with um some of our clients is uh surgeons are listing three or four people you can only build one assistant um another surgeon trumps your physician assistant so um you know on the as modifiers when you would use the physician assistant that's fine to list um you know that there were multiple assistants in there but the primary surgeon needs to document who the primary assistant was and what role they played you can't you know you can't list all these people and then leave it up to the coder to guess um it has to be clear and and um precise because they medicare will not pay for these if they are not seeing the required documentation now when you're going to use an 80 that's again with another surgeon um 81 is actually a minimum assistant modifier i we don't use that a lot in our area 82 is if you have um you're in a teaching facility 82 signifies that yes we're in a teaching facility but a qualified resident was not available that again has to be documented in the note if it if you're a teaching facility and again that as signifies that you're talking about a physician assistant so this kind of breaks this out more um basically reiterating what i just said so next let's talk about co-surgeons and team surgeons so when we when we have co-surgeons we have two or more surgeons that are skilled to do surgery on the same patient same session again a great example is a tavern you have um you know a ct surgeon and an interventional radiologist or cardiologist not a radiologist um but each are of a different specialty that is a medicare rule the only exception to that is heart transplant um and that that's a whole different ball game there but they do have to be different specialties so if you have two ct surgeons performing a cabbage they cannot build that with a 62 modifier if you have um two vascular surgeons performing an um an evar they cannot both build that with a 62 however if you have a vascular surgeon and an interventional radiologist performing that evar then they would need to report it with a 62 it does requirement that each surgeon document their own note on what they performed um and then again if if one bills with a 62 and the other one doesn't you're going to get that cms will return that claim unpaid and then what they do with that when you have a 62 they increase the procedure reimbursement to 120 percent of what they allow and then they split that and 62 and a half percent goes to one surgeon and 62 and a half goes to the other so um keep that in mind because we see this a lot where and i i know surgeons get upset about it but when you're in the same specialty and you're billing for medicare you cannot use a 62 modifier so a lot of times what i you know when i would run into this with my own practice you know i tell them hey start tag teaming and take take terms one of you be primary on one and the other one be primary on the next procedure for 66 this is a team of surgeons um that are more than two surgeons of different specialties again so they can't you know now this would be um you could have a vascular surgeon a ct surgeon interventional radiologist um performing something and then they would report that with the 66 and then they would report that with the 66 um also you do not now keep this in mind because a lot of people don't know this either you don't need a modifier if surgeons of different specialties are each doing a totally different procedure even if they're going through the same incision so one of the things i could point out on this if if you have let's say a ct surgeon performing an esophageal procedure and then a general surgeon is removing a kidney and they're going through the same incision that's fine neither one of them need to report they just report what they did um and without modifiers because um they're not they're not performing a co-surgeon on the same organ so keep that in mind and then again this is um that's the example i already talked about cardiologist ct surgeon performing that tavern that is an ncd requirement where we've been seeing some of this too where um you know all of a sudden the cardiologist is doing this without a ct surgeon you can't do that but the national coverage determination for medicare for taverns state you have to have a cardiologist and you have to have a ct surgeon they each must perform their procedure together so again none of these surgeons dictating i stood in the corner and scrubbed in that that's not going to cut it they each have to be involved they each have to dictate what they did so that being said thank you for your patience on um my struggling voice i appreciate that i'm now going to turn it over to jamie and she is going to take us through the other modifiers all right well thank you jolene all right everybody so we're going to start with two modifiers that we know very well um our 26 and our tc so as we know the 26 modifier is applicable um only to the professional component only um and then of course the facility um would report the tc modifier on that applicable code you can check the medicare physician fee schedule like jolene was stating earlier with the global um assignments um that physician fee schedule also tell you if a 26 and a tc modifier are applicable to a code so sometimes you'll have the global code meaning the full code without the 26 or the tc so an example of that might be if you have your own cath lab in your office um and you're reporting you know just a standard left heart cath that you can report that without the 26 or the tc and then the insurance would process the claim and pay for both of that professional and technical component but when you're in a hospital setting um you know a service like a left heart cath the billing is going to be split because the facility is going to charge for their portion and then the provider is going to charge for his professional or his or her professional portion so again just check the medicare physician fee schedule um know when the modifiers are applicable depending on the location and where you're providing the service all right next slide all right so modifier 25 this is another one we know well um as we know so it's defined as a significant separately identifiable evaluate evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service so we definitely use this modifier a lot in our world um we would append it when it's supported of course by documentation and when another service is being provided same day um tons of different scenarios of when you may apply it so if you're in a hospital jolene go ahead and skip to the next slide i think those have some examples yeah so here's an appropriate use of it so patient presents to the emergency room with severe chest pain and shortness of breath the decision was made following the e&m service to take the patient to the cath lab for a diagnostic cath and possible intervention so because the provider had to see and assess the patient first and at that assessment is where the decision was made to do the cath that's why you would be allowed to append that modifier 25 because it is a separate identifiable service that was provided now if um if it was a planned cardiac cath um you know and actually go ahead and skip to the next slide because i believe that was an example on that one of inappropriate use so yeah patient presents to the hospital for a scheduled cardiac cath and physician dictates an h&p to satisfy the hospital requirements this is a very common scenario most hospitals do require that there be an h&p in the patient's chart if it's scheduled from you know the provider is already seeing and assessing the patient and from that assessment they schedule that procedure and now they're satisfying the hospital requirements and dictating a new h&p that's not billable they've already made the decision from that prior visit to perform this procedure so yeah they may still have to dictate a whole nother h&p to satisfy the hospital requirements but that doesn't mean they get to bill it now if they do come in for that scheduled cath and the patient is having a whole new complaint that they have not had before and now the provider needs to address that to see if they should continue on with the scheduled procedure that that could be a scenario where you may still be able to append it because they're addressing something totally different and unrelated and new to the patient another scenario is and we do see this a lot too patient could be in the office setting they're having a non-invasive test done like a nuclear stress test or maybe an echocardiogram and since they're already in the office and you know the provider or the app matt may have you know some availability on their schedule they go ahead and decide to see the patient and kind of give them those results of that test that's not going to be separately identifiable and nor will it support that 25 modifier so and actually in your um ama cpt book um at the very front of the um book when you start opening up and you know looking at all the different guidelines that they have printed within the book there's actually a section there that states that part of performing a test is giving the patient those results so again not separately reportable to give the patient the results only are they addressing other conditions that were not related to why they ordered the testing you know stuff like that um you know to justify that 25 if it's just given test results it's not going to be separately billable on the same day they perform the test all right next slide all right so modifier ai we don't append this a ton in our specialty but we can't definitely can so um this is when a patient is admitted into the hospital um and the primary admitting provider would be appending this modifier ai this identifies to the carrier that that provider was the one actually admitting and overseeing the patient's care during that hospital stay so again we don't do it a ton normally it's a hospitalist that is um doing the admission but there are apps there are scenarios where we would append this um you know a patient comes in through the emergency room um an active STEMI is called um the cardiologist is going to take full control over that patient and actually take them emergently to the cath lab all you know that whole kind of scenario um you know and then they would actually be doing that admission note so definitely can be um appended it's just going to depend you know of course on the who admitted that patient to the hospital so um just keep that in mind if you are the admitting make sure you get the ai on there i do know there's some commercial carriers out there because of course with our hospital reporting of our enms um you know we're instructed to report the initial um admission codes now because they got away with our they went away with our consult services um a long time ago um i do know there's still some commercial carriers out there that still do give um issues on processing the claims correctly um and you know and i do know there's some practices that we work with that still have to appeal those denials um so again it's just going to be carrier dependent of course but if you are the admitting provider definitely don't miss adding that ai modifier because it will it will definitely affect your claim um especially with those difficult carriers all right next slide so inappropriate use of the ai um when the patient is admitted by the family physician or a hospitalist and then a request for the patient to be seen by a cardiologist is given and the cardiologist performs that enm service for the patient so they would not they're they're the consulting provider at that point um so they would not append that modifier ai um they would still maybe report the same code that the admitting providers reporting also um but again that ai would not apply to in this scenario because we would be the consulting provider all right next slide modifier fs this one's fairly new in the last couple years this is a split or shared evaluation and management visit and this is um a modifier that medicare created so they can easily track split shared services now because as we all know uh split shared has definitely been a hot topic on medicare's radar for the last several years so um this is just an easier way for them to now track when a split shared service is provided all right next slide so correct use of fs of course is when an enm service in the hospital facility setting is split and shared between a physician and a non-physician practitioner in that facility setting so remember split share does not apply in the office setting when you're reporting places service 11 this is facility reporting only so um and that again that would be an example when not to use it if it's in that office setting okay modifier GC, this service has been performed in part by a resident under direct supervision of a teaching physician. So if you do have a program where you provide teaching services, definitely wanna keep this modifier in mind. Claims must comply with the requirements described in the general documentation guidelines and the E&M documentation guidelines. And I cited the pages that they specifically cover. I actually was looking at the guidelines yesterday, so this is the most accurate information. And they just go through what exactly has to be documented. Of course, they have to document that the teaching physician was readily available and available and all that stuff and present for the critical portions of the service. And then again, you would just apply that modifier GC from there. Next slide. So again, appropriate use. GC modifier is applied to services in which a resident furnishes a service when a teaching physician is physically present during the critical or key portions. And that's the link on the slide here to that. And then if you go to those pages I cited on the previous slide, that will take you directly to what the requirements are. And then inappropriate use is when a resident performs a service without a teaching physician present, you cannot then append that modifier GC. And then also a mid-level provider cannot supervise a resident. Modifier GE, this service has been performed by a resident without the presence of a teaching physician under the primary care exception. So not something we see a whole lot in our cardiology world, but another modifier option for teaching services if it's applicable to your program. All right, so this is, we're gonna get into some of our NCCI edit type modifiers next. So Medicare claims processing manual, the purpose of the NCCI, which is the procedure to procedure edits is to prevent improper payment when incorrect code combinations are reported. So if you've ever pulled up the NCCI table that Medicare releases, it's like on an Excel type spreadsheet and it's got a lot of numbers that are, you know, CPT codes that we report. And it'll go through and tell you in column one versus column two, if services kind of bump against each other or not. So when they do, that's when we are gonna go ahead and look at our next slide, Jolene, and that's when we're gonna append either a modifier 59 or there's X modifiers, which we'll cover. But we'll start with the 59 first because this definitely is carrier specific. We know Medicare some years ago created these X modifiers, which there's four of them, but some carriers do not accept those modifiers. So the 59 is what you would use. So under certain circumstances, it may be necessary to perform services or procedures that are distinct or independent from another non-E&M service performed on the same day. So example here could be the provider orders that diagnostic cardiac cath with possible intervention. That's a common order that we see, but they may not always know, you know, upfront if they're going to be doing that intervention. They have no idea what they're gonna find without doing that diagnostic cath. So while they're doing the diagnostic cath, they make a decision based on the findings that they see that, oh, in this example that we have here on the slide, that right coronary artery needs to have a stent placed. So that decision was made based off of that diagnostic cath that they perform. Well, the cath and the stent code will bundle together so that with that NCCI edit, but because, you know, the decision was made after the cath was performed and the provider reviewed those results, you would want to append that modifier 59 to the cath, that way it would pay separately from the stent also. Next slide. So in inappropriate use here in this example, kind of a common one we see again, patient had a cardiac cath two weeks prior where it was discovered that the patient had a chronic total occlusion of their left circumflex artery. Patient presents today to have an intervention done to that CTO lesion. The left heart cath was performed and a drug eluding stent was placed in the proximal left circumflex and the mid left circumflex along with the distal left circumflex. So the 92943 with an LC modifier would be appended. You would not separately bill for the cardiac cath because you just had one done two weeks prior. They already knew about the CTO lesion in the LC artery. So this would be a staged intervention. The only way they could report a new cath in a scenario like this is if the patient starts complaining on the cath lab table that they're having severe chest pains or shortness of breath so their condition is changing and therefore the provider wants to check and make sure there's been no changes. Sometimes they may not be able to, some of the findings from the prior cath may not be fully clear in the imaging so they may wanna repeat. So there has to be documentation to really support that. But in this kind of scenario, when it's a staged intervention, nothing's changed in that patient's condition, you would not separately report that cath in this case. All right, so now our X modifiers. So Medicare created these. And again, this is gonna be dependent on your carrier. There's several different Medicare contractors out there. Some require these X modifiers, some are still okay if you just report the 59. So it really is just gonna vary on your specific carrier. Commercial carriers also vary. And that's gonna vary across the country even because I know some programs that we work with, they may have a Blue Cross plan that does not want the X modifiers at all, they require the 59, but you could have an Aetna policy or a Cigna plan that they're fine with either. So just know your carriers and what their preferences are for sure. But in a case where you do have a carrier that is still, they want the X modifiers, you have four different options to choose from. Jolene, go back to, yeah, sorry. So you have four different options, it's gonna depend. So you have an XE, which is for a separate encounter. And that would be a service that is distinct because it occurred during a separate encounter. So it could be where the patient had a procedure done earlier that day, and now they're being brought back into the cath lab for, they could be having new symptoms or something else happened and that's requiring them to be brought back in same day. So that could be a scenario like this where it's been a separate encounter. XS is a separate structure. So that's when the service that is distinct because it was performed on a separate organ or structure. XP is a separate practitioner. So again, that's pretty self-explanatory. And then the XU would be unusual non-overlapping service. So the service of a service that is distinct because it does not overlap usual components of the main service. So in a case where you may have a carrier that wants the X over the 59, and we have that scenario that we've already talked about where you're doing that diagnostic cath. And based off of those findings, we're gonna go ahead and do that stint. And if your carrier takes the X, then the XU would be applicable to that cardiac cath code. So again, check with your payers if you don't already know what their preferences are, and then just kind of go from there on how you apply, whether it's the 59 or the X modifiers. All right, next slide. All right, 52 versus 53. So this is a reduced or discontinued services. How you report these depends on the circumstances rendered. So if you have, so modifier 52 is under certain circumstances, a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified healthcare professional. Modifier 53 is under certain circumstances, the physician, again, or qualified healthcare professional may elect to terminate a procedure or service due to extenuating circumstances or those that threaten the wellbeing of the patient. So you would not use the 53 for elective cancellation of a procedure prior to that patient's anesthesia induction and our surgical prep for the OR or the suite. All right, next slide. So these are examples of when these would be appropriate to use. So with modifier 52, we have a patient without known structural heart disease. They have a history of permanent asymptomatic AFib. They present to the physician's office with daily episodes of narcinkapy. They order a 48-hour holter. Upon return of the holter and reviewing, you know, the tracings and all that that was sent, it was found that the patient's monitor was only worn for 10 hours of that 24-hour period. Now, remember with the 48-hour holter, it's 24 to 48 hours. So in your CPT book, it does give instructions that when it's worn less than this 10-hour timeframe, then you would have to append that service with the 52 in that kind of case, because you're not wearing it at least for that 24-hour period. So in this scenario here, the practice actually owns the equipment. So they're able to report that full global holter code, the 93224. So again, since the patient only wore it for 10 hours, but that only resulted in nine hours of recording time, they have to append that modifier 52 to reduce it. For modifier 53. So in this scenario here, we have a patient that presents for a CTO intervention with a stent. Now, CTO interventions just in itself are more complex because of the sheer fact that the patient's vessel is fully blocked. So a lot of times, those take a lot more time. That's why that is the higher reimbursed intervention that we have for our cardiac PCI services. So when we're looking at a case like this, so here the patient is prepped and draped, access is obtained through the right femoral artery. The catheter is threaded into that right coronary artery. They then put the wire to cross the lesion. It took several attempts with the balloon to cross, but they did finally get it through and inflate it several times, but they could not get it fully expanded. During this procedure, the patient then became unstable. And as a result, it was decided to abandon the procedure. So because the fact that the patient became unstable and they could no longer continue, that would be an example of when you would want to report that 53 modifier because that had extenuating circumstances that was threatening the patient's stability at that point. All right, modifier 76 and 77. So these are for repeat procedures. 76 is where it signifies a procedure that is repeated by the same provider. And then the 77 is repeated by another provider. And examples of this, both examples have EKG. So we have a patient in the ER with chest pain, an EKG was performed. Later that same day, another EKG is performed by the same provider that did the original one. So I can't remember what the MUE assignment for an EKG is. It's several. It might be something like five. It's from three to five. I just, I don't have it memorized obviously, you can report multiple EKGs same day in the facility setting especially. And it is common that they could have multiple EKGs done same day. So again, when it's done by the same provider, same day, you would just append that second one or even the third one with that 76. Now, if it's done by a different provider, say the emergency room, well, not the emergency, say you had a general cardiologist do the first one and then maybe an interventional cardiologist or even the same or a different general cardiologist in the same group looks at the second one, that would be a different provider. So you would report that 77. Another good example for the 76 that I see a lot in the EP world is if you're able to report the periprocedural programming and let's say we have SVT ablation. So the periprocedural programming of the patient's device can be billed with an SVT ablation, but a lot of times they're going to evaluate that device before they start the procedure, they're gonna change settings or sometimes they turn off the settings, they perform their procedure and then after the procedure is complete, they reevaluate the patient's device and they reprogram it. So that's a scenario here also where you could append, you would append the periprocedural service for the start of the case and then you would report it again for at the end of the case. So it'd be a repeat also. So the 76 would be applicable in that kind of scenario. All right, modifier 22. So this one definitely can cause some controversy at time. This is an increased procedural service. It's reported when the work required to provide the service is substantially greater than the typical required. So what we recommend at MedAxiom is that the provider document a separate paragraph within the report describing the extra time, difficulty, the additional work, any specifics that they feel are applicable to support that 22. Again, if what's standard for them for a regular, maybe a regular stint to do in the cath lab, maybe it's, I don't know, 15 minutes or something, but they have one where they're having issues accessing the vessel and just based off the patient's anatomy, whatever the circumstances are, and it's actually caused them double the time just to do the same procedure that they can normally do in 15 minutes. That would kind of be a scenario like that. But they need to describe that difficulty, any additional time that they feel is applicable, the severity of the patient's condition. Again, any abnormal anatomy, all that detail. When you append the modifier 22, it's going to hold up your claim because that carrier is obviously gonna wanna see the op report to justify giving you more money. So keep that in mind too. So if you don't have a lot of success with getting additional reimbursement when you append the modifier 22, you may just wanna look at certain carriers and deciding whether or not it's worth trying to fight that battle. If you have really good documentation, there should be no reason why your carrier does not give that additional reimbursement, however. All right, next slide. All right, so we're gonna go through some tips now. Let's start with the ideal operative report. So as coders, having all this ideal information would be wonderful if we could get it in every single op report we all look at, but we do know it's not a perfect world. Some of our providers use templated reports. So sometimes we don't get all these ideal sections that we would prefer, but ideally it would be great to have your preoperative diagnosis, your postoperative diagnosis, because again, as they get in there, they might find relevant findings, especially like if you're thinking about a cardiac cath, for instance. So a patient might be coming in with severe chest pain, shortness of breath, and maybe they had an abnormal nuclear stress test. Well, that's what your pre-op diagnosis is. Well, now that they've gone in there, done the cardiac cath, they see that the patient has multi-vessel disease. Well, that's your relevant findings now. So that's gonna be your primary diagnosis on your claim is what the actual findings of the study are. So that's why it's nice to have the pre-op diagnosed and the post-op diagnosis documented within the report, but sometimes they put it all in the same section. So, again, it's just gonna depend on the provider and how they like to dictate their stuff. Again, if there's any additional surgeons or assistants involved, those details are definitely helpful, especially with certain procedures where sometimes you may have another provider involved. A good one I can think of off top of my head is a Watchman implant, because that service is allowed to have a modifier 62 appended if it's supported. And sometimes we do have an interventional cardiologist and the electrophysiologist both participating in the Watchman implant. So that would support that modifier 62, but it is helpful when each provider references the other provider that they're involved with in the note itself. So it is helpful when you can just see that in the independent report. Again, any indications, which would be part of your pre-op diagnosis, relevant findings, of course, that's gonna be part of your post-op, and then your procedure description. So what we typically refer to as the wishlist of what they intend to perform, of course, we're gonna verify that in the body of the note. But again, that's ideally how an op report would start. The next slide, please. The ideal operative note, again, continued. So these bullets do not affect coding, but it is, of course, helpful when you have this additional information documented. So again, anesthesia, was a general anesthesiologist involved, or did you provide moderate anesthesia, moderate sedation? That's gonna change, because if you do provide moderate sedation and those documentation requirements are met, you can bill for that. But if general anesthesia is involved, then, of course, they're gonna bill for that portion themselves. But again, just knowing what you're working with is helpful when you initially look at your report. Again, all the other stuff is just, it won't affect your coding, but just always helpful to have, especially when a carrier requests their note, just having everything all in the same area is helpful. All right, next slide. All right, prep work to capture correct coding. So again, when you initially look at your report, first thing we initially see is usually the indications, the reason why they're performing it. So that's gonna be your pre and post-op diagnoses initially. And then, of course, you're gonna wanna capture anything additional with what they may have found while they were in there doing the service. First review of the operative procedure, capture that initial CPT code listed for the procedures performed. Some providers will list out what we call that wishlist again, and they will list out everything that they intended to perform. But that doesn't mean they always performed all that. So again, you wanna verify that in the body of the procedure report. But it is nice to have that, just to look at it to see, okay, this is what they said they did, but now we're gonna verify, did they actually do all this? Next slide. All right, review the continued with the work performed. So again, review findings and indications. You're always gonna wanna report your findings first. That's always gonna be primary. And that's true for anything, whether it's a procedure service, a non-invasive diagnostic service. You could have done like a 30-day event monitor. You ordered it for palpitations, but the event monitor showed the patient was going into a complete heart block several times, and they also found that the patient was in AFib a lot. So you're gonna report those findings over the palpitations. That was the reason, the symptom why they ordered it, but they actually found a definitive diagnosis. And then again, you wanna check for any assistant or co-surgeons. Jolene covered those thoroughly. So there is a difference with reporting and appending those specific modifiers. So as you're reviewing the operative report, the actual meat of the note that we code from, you confirm everything that the provider put in their wishlist. You wanna make sure you're matching services. So if you have co-surgeons involved, just making sure both providers have documented independently what they performed. If there's any assistance involved, making sure that assistant is clearly documented and what portion they provided to assist with. So just all those details. Once you've identified all the procedures performed, you then wanna make sure you capture all those. Some of them may be an add-on code. You wanna make sure if there's, you wanna check your NCCI edits and making sure if there is an edit that a modifier would be supported to override the edit. If not, then you wanna make sure you eliminate reporting that service additionally. So all those details while you're reviewing the meat of the note. All right, and then anatomy of the ideal operative report. So again, final codes chosen describe what they did, not what they intended to do in that wishlist or may have failed to do. Sometimes we see stuff listed in the wishlist and you see it nowhere supported in the operative report, in the body of the note itself. So you would definitely not report it if it's not supported as being performed. Although important for us to know in general, CMS does not care about the type of incision or approach. It does help us, especially if you're looking at vascular type studies, knowing the access sites is definitely important when you're looking at cath placement coding and all that. But when you see the access side and the approach and where they move the catheters to do whatever they were doing, it does kind of help paint the picture and help guide you as you're reading your note. And then you wanna focus on the actual work done to choose your codes, not how difficult. So again, and definitely check your NCCI edits. All right, closures. So identify all specific finished work. You know, if they were weaned off bypass, surgical site closure, placement of all drainage tubes, all that kind of stuff. Now, closures themselves are not separately reportable. You know, provider has to close the patient when they open them up. From a facility reporting perspective, the facility, if they use a closure device, the facility does get to report that device because they're the ones purchasing it. But again, that's gonna just vary again, and you're talking about facility coding, not provider professional reporting. So just keep all that in mind. All right, and then basic processes to achieve correct coding, review and finalize diagnostic lists based only on what is documented in the op note. So again, I know I've said it several times, you don't ever code from the wishlist ever. You code from what is supported in the body of the procedure. And if you're not sure of something, that is when you want to address that with the provider, whether it be you send them a query or however you communicate with your providers, you would definitely wanna reach out to clarify. All right, and then that brings us to the end. So tomorrow, if you're registered, I'm gonna be discussing advanced EP case studies. I did do an EP series this year. So this is kind of the fourth of that series. And it's gonna be very heavy case examples. I think I've hit 10 cases total for us to review. So if you haven't registered for that, go ahead and jump on our MedAxium Academy site and get registered for that tomorrow. And then Thursday, Nicole and Linda will close us off with non-face-to-face coding and documentation opportunities in our CV care. And then with that, our disclaimer, CPT, and then questions. So there are a ton of questions in here. I know we've been tag-teaming and answering several, but there are still several more. So we'll see if there's any Jolene and I can tag-team together here. Let me get this open. All right, here's one here. EP implants a pacemaker. A few weeks later, the patient presents to the emergency room for chest pain. During them evaluating the patient, they see that the pocket is infected. Is this unrelated to the implant or would this be a global post-op? So this is a great question and it's gonna be dependent on the carrier in a sense. So Medicare doesn't normally pay if there's an issue during the post-op period that's related to the global period. But I would still report it and try to get it processed because it's not something that's expected. You don't expect for the patient's pocket to get infected. So commercial carrier-wise, I know that they're a little bit more lenient with scenarios like this. Medicare may be a little bit harder. But like I said to me, the provider does not put in that device automatically, thinking the patient's gonna be back in in a couple of weeks with an infected pocket. So again, definitely would still report it as non-related and then just it's gonna be carrier-dependent from there. Hey, Jamie, I have one. Can you please go over the modifier 57 again? They thought that I mentioned we don't need the modifier in certain instances. So 57 is to be used the day before or the day of a major surgery with a 90-day global. Now, what I was talking about is if the patient had come in the office, it's an elective surgery, they've determined that they're going to do surgery, but they're scheduling that out for a couple of weeks or a month or whatever the case may be. You don't need to put the 57 on that E&M service that's being done in the office. It's only applied if it's the day before or the day of, and it has to be the decision to perform that surgery. So again, if let's say the decision was made a month ago and now they come in the ER or not ER, they come into the hospital and to satisfy the hospital, the doctor has to dictate another H&P. You're not going to bill that code. You're not gonna bill that service with a 57 because that decision had already been made. And here's another one here. In case of emergent cath and intervention for a myocardial infarction, can the E&M be billed by the interventional cardiologist? So did the interventional cardiologist see the patient in an emergent situation and then from there activate the cath lab? So if you have a scenario like that, where they're making that emergent decision to bring them to the cath lab, then yes, your E&M is gonna be separately identifiable in that kind of scenario. Okay, and I have one. CT surgeon performs CABG for CAD, cardiology slash interventionalist round day after for CAD. No other condition other than the CAD meds given. Can the cardiologist code for that hospital visit? Absolutely yes. That global belongs to the surgeon, not the cardiologist or the interventionalist. And keep in mind when the surgeon's seeing a patient, they're not treating the disease per se on that post-op. They're looking at the incision. Is it bleeding? Is it infected? Did they happen to go into AFib or something to that effect? When the surgeon is doing that, they're in that global. But the cardiologist should be able to bill without any modifiers. Now, sometimes you have to argue that point and fight for that point. And the question did go on to continue. If AFib is post-op and cardiology rounds, is that included in post-op care? That's included for the surgeon's post-op care, but not the cardiologist or the EP. So again, a lot of that comes down to how are your providers credentialed and make sure those that are in that specialty are credentialed in the correct specialty. All right. I have a couple on that I can take back to back, Jolene, here. So one is, could you repeat what you said about Blue Cross not accepting X modifiers? So this is going to be region-specific. So what I was saying in my example is I know a certain, we have a couple of clients that we work with that are in certain regions where I know just based off of working with them and what they know from their specific carriers that in that specific region, that Blue Cross carrier does not accept the Xs. But that could be different in your region. So just like I said, check your big payers and see what policies they have. And if they do accept the X modifiers, then I would recommend reporting those because they're more specific than just the 59. You can break it out because there's four different choices. So those kind of give a clearer picture to the carrier. But if you have a carrier in a certain region that does not want the Xs at all, then that's when you would just report the 59 instead. And then next one I can grab here is, our cardiology practice performs EKGs, sometimes several in one day, with or without procedures. Are we limited to 76 and 77? Or can we use the 59 or X modifiers as well? So that's a really good question. So when you only have EKGs done same day and you have several that are repeat, that's when you're going to append the 76 or 77. But say you have multiple EKGs done same day and another service. Say they had an echocardiogram done same day, or maybe they had a cardiac cath. Now you have your multiple EKGs being done, but you also have a separate service being provided as well. So you may have some times, you may have some scenarios where you're appending both, whether it be a 59 or the X, depending on your carrier preference. And you're reporting the 76 or the 77, depending if it's same provider or a different provider repeating that EKG. So again, going to depend on your scenario and what all was given to that patient for services that same day. But good question. I have one more here I think we have time for. If a patient is admitted and undergoes a major surgery after four days of an inpatient stay, can you explain the global package in this scenario? So I think if I'm reading this right, so let's say the patient got admitted on the 18th and we didn't do surgery till the 21st. Well, the 18th would be a billable service. The 19th would be a billable service. The 20th would not, because that's the day before your major surgery. And this would apply to the surgeon, not anybody else. So the day before, which would, what did I say, surgery 21st. So the day before surgery or the visit on the 20th would not be billable. Nothing billable on the day of the 21st other than the surgery itself, unless something else is being taken care of that's not related to that surgery. And then you have 90 days from the 21st on is all part of that major surgery package. But keep in mind, you need to look at your fee schedules and they'll let you know how many days a procedure is actually, what their global timeframe is. All right. Well, that takes us to the end and we're right at 2.30. So again, please make sure you join me tomorrow for some EP fun. If you love or get hives with EP, we're gonna go through lots of cases and I am gonna go ahead and plan for another advanced session next year as well. Cause it's always such a hot topic, but definitely make sure you join us tomorrow. And then Nicole and Linda will end our bootcamp week on Thursday. And we wanna thank you guys for joining us today. Thanks.

surgical coding

modifiers

global surgery package

claims processing

Medicare

postoperative periods

documentation

modifier usage

assistant surgeons

repeat procedures

operative notes

coding principles

Q&A interactions