CPT Surgery and Procedural Coding
What this domain tests
Surgical items cover the global surgical package, global periods, modifiers, multiple procedures, bilateral and assistant surgery, and add-on codes.
Core rules
- The package includes the preoperative evaluation, intraoperative services, typical postoperative care, and supplies. Global periods are 0, 10, or 90 days.
- Modifier 24 is an unrelated E/M during a global period. Modifier 25 is a separate E/M on the day of a procedure.
- Modifier 57 is the decision for surgery for a major (90-day) procedure; it is not used for minor procedures.
- Modifier 58 is a staged or related procedure during postoperative care; 78 is an unplanned return to the OR for a related procedure; 79 is an unrelated procedure during the global period.
- Modifier 50 reports bilateral procedures; 51 signals multiple procedures and payer reduction. Add-on codes do not take 51.
Worked example
A patient has an open inguinal hernia repair with a 90-day global period. On day 20 the wound dehisces and the patient returns to the OR for repair. Report the return procedure with modifier 78; do not rebill the original hernia code and do not use 58, because the return was unplanned. The payer covers only the intraoperative portion of the return.
Traps
Billing 99024 for a routine postoperative visit; using 57 on minor procedures; using 58 for an unplanned return; unbundling with 59; omitting 50 for bilateral work; reporting an add-on code without its primary code.