CPT and Medicare Surgical Packages

The Current Procedural Coding (CPT) has a definition of the surgical package that outlines what is considered incidental or included in the surgical package, however it does not go into great detail. The detailed description is given by Medicare, and is what most insurance companies follow.

Medicare provided a definition of surgical package to ensure that Medicare contractors across all Medicare Administrative Contractor jurisdictions make payments for the same services uniformly. The role of the policy is to ensure that Medicare payments for services are not more or less than intended. Consistent payment policies and requirements for claims processing are established for other surgical issues, such as multiple and bilateral surgeries, team surgeries, and co-surgeons (Smith, 2011).

The CPT surgical package includes the pre-operative, intra-operative, and post-operative services. The pre-operative services are; local infiltration, metatarsal, metacarpal, digital clock, and topical anesthesia. It also includes one related E/M encounter on the date immediately prior, or on the date of the procedure subsequent to the surgery decision. Intra-operative includes actual surgical procedure while post-surgical services are; the immediate after operative care, notes and dictation. It also includes talks with other physicians and family, order writing, post-anesthesia patient evaluation and uncomplicated post-operative care (Smith, 2011).

Smith, (2011) further notes that the Medicare definition is the same in the pre-operative and operative services, but differs in the post-operative services in a more expansive manner. It includes all additional surgical and medical services by the practitioner to complications, without additional trips to the operating room. Recovery related follow-up visits to the operating room, pain management after surgery, supplies that are not exclusions are included. Miscellaneous services, for instance local incision care, removal of cutaneous staples and sutures, operative pack, tubes, wires, lines, splints, drains, and casts. Dressing changes, irrigation and removal of urinary catheters, insertion, changing of tracheostomy tubes as well their removal are also included. 

Smith, (2011) explains that in CPT, suture removal is included in the package as typical uncomplicated post-operative care while in Medicare, it is no longer included in the procedure codes though billing depends upon the operating group’s philosophy. Some CPT codes have the term Separate Procedure within the descriptor. For example, a surgeon notes that a diagnostic anoscopy was done, during which a biopsy of the rectal tissue was used. 46600, diagnostic with or without collection of specimen by brushing or washing (Separate procedure) then, 46606, with biopsy single or multiple. Since 46600 is designated separate procedure, it would not be assigned with 46606. The right assignment procedure would only be 46606.     


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