Best Practices when Assigning Critical Care in the Postoperative Setting
Patients admitted to the ICU after surgery are frequently sent there due to an expected critical post operative phase of their recovery. Open heart surgery, complex neurosurgery and complex vascular cases come to mind for this scenario. Since these high risk surgeries have a 90 day global postoperative period associated with them, coders have to consider, what is the best way to navigate these murky waters?
In today’s world, critical care in the acute postoperative phase is relegated to an intensivist who monitors the patient and manages their airway and hemodynamics. This has really become the norm. Patients who have open chest surgery are under heavy intraoperative sedation and take longer to fully wake and resume their own breathing. An uncomplicated or expected recovery to the point of successful extubation for these patients is within the first 24 hours after surgery. Hemodynamic stability post operative is really dependent on the patient’s pre-existing co-morbid conditions and the patient’s general preoperative health.
Similarly, coders frequently find documentation in the medical record for post operative respiratory failure, even when a patient was extubated within 6 hours of admission to the surgical ICU and is now sitting up on 2 liters of oxygen per nasal cannula. Post operative respiratory failure in these cases would be warranted if there was an inability to wean and extubate the patient from the ventilator or there was a need to reintubate the patient. Air leaks from the chest tube(s) that are small and do not need to be treated with more than hooking the patient’s chest tube to suction and are not causing dips in Sp02 may or may not support a “critical” picture. A query to the provider is warranted when there are questions.
Post operative shock or cardiogenic shock is a valid diagnosis if the patient is hemorrhaging or there are lethal cardiac arrythmias, or circulatory pressures can’t be adequately maintained with the normal vasopressors. The inability to wean a patient off of pressors due to whatever reason (which must be stated) is an acceptable reason to code shock.
The following excerpts from the Medicare Internet Only Claims Processing Manual 04, Chapter 12 indicates the following:
“30.6.12.7 - Critical Care Visits and Global Surgery (Rev. 11288; Issued: 03-04-22; Effective: 01-01-22; Implementation: 02-15-22) Critical care visits are sometimes needed during the global period of a procedure, whether preoperatively, on the same day, or during the post-operative period. In some cases, preoperative and postoperative critical care visits are included in procedure codes that have a global surgical period. In those cases where a critical care visit is unrelated to the procedure with a global surgical period, critical care visits may be paid separately in addition to the procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (for example, trauma, burn cases). When the critical care service is unrelated to the procedure, 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.)) to the critical care CPT code(s). If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), modifiers -54 (surgical care only) and -55 (postoperative management only) must also be reported to indicate the transfer of care. The surgeon will report modifier -54. The intensivist accepting the transfer of care will report both modifier -55 and modifier -FT. As usual, medical record documentation must support the claims.”
“30.6.12.8 - Medical Record Documentation (Rev. 11288; Issued: 03-04-22; Effective: 01-01-22; Implementation: 02-15-22) When critical care services are furnished in conjunction with a global procedure, the medical record documentation must support that the critical care was unrelated to the procedure, as discussed above.” clm104c12.pdf
Medicare has maintained that the surgeon doing the surgery is expected to have the skills to recover the patient. In the event care is transferred to the intensivist, “to” and “from” dates must be included on both the surgeon’s and the intensivist’s claim for most MACs.
CMS finalized HCPCS code G0559, an add-on code used to report services for post-operative care provided to a Medicare beneficiary by a practitioner that did NOT perform the surgical procedure. The code was created by the agency to capture the time and resources needed in these instances. The code may only be coupled with an office E/M service for new or established patients. Also, G0559 is only billable once during the 90-day global period. Recent publications by CMS further support the use of G0559 is not appropriate in the inpatient critical care setting. Please see mln907166_global_surgery_booklet.pdf and the most recent FAQ for this on the CMS web site. faqs-strategies-for-improving-global-surgery-payment-accuracy-final.pdf
“Q: What code should be billed when a practitioner sees a patient for a post-operative visit and they did not perform the procedure, and who can bill the code?
A: We created a new code, HCPCS code G0559, beginning in CY 2025, that may be billed by the physician or practitioner who furnishes the post-operative office/outpatient E/M visit when the surgical procedure portion of a global package service is performed by another practitioner in the case of a 90-day post-operative visit.
Q: Who can bill the add-on code, and is there a frequency limitation?
A: The add-on code (HCPCS code G0559) can only be billed by a practitioner who did not perform the actual procedure and is not in the same group practice as the surgeon. HCPCS code G0559 may only be billed once during the 90-day post-operative period.
In closing the takeaways from this article are 1) Critical care in the post operative period is billable when a patient is critical and the diagnosis driving critical care it is not related to the surgery. 2) Patients who have had a high risk procedure and are recovering as expected should not be billed for critical care. 3) If the patient is critical and care is transferred from the surgeon to the intensivist, modifiers 54, 55, and FT need to be appropriately appended. 4) Do not use G0559. 5) The medical record must support the critical clinical picture, and the reasons the patient’s critical condition is unrelated to the surgery or above and beyond the expected post operative recovery. Coders and billers should investigate similar policies with private insurance.
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