What's the difference between major and minor procedures?

Cracking the Code

Dirk Elston

Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has served on the AMA-CPT Advisory Committee.

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I volunteer as teaching faculty at the university dermatology clinic. I have been told that I have to be present for the entire procedure if it is a “minor” procedure. Does this mean any procedure with a 10-day global period?

First off: Thank you for volunteering, and giving back to the specialty. In regard to the question of whether you have to be present for the entirety of a minor (10-day global period) procedure, in an inpatient setting, Medicare states that for minor surgical procedures (lasting less than five minutes), the teaching physician must be physically present during the entire service. As for major procedures (lasting more than five minutes), the teaching physician must be physically present during the “key portion(s)” of the service and must be immediately available to furnish service during the entire procedure. The teaching physician must then document the extent of his/her participation during the procedure. However, your teaching faculty may have a different policy for services or procedures performed in an outpatient setting; check with the coding and compliance office at the university. It is likely that you only have to be present for the key and critical portion(s) of the procedure(s), unless there is a medical reason for you to be present for the entire duration of the procedure.

There has been considerable confusion over this point, as the Centers for Medicare and Medicaid Services (CMS) uses the terms “major” and “minor” in more than one context. In regard to use of the 57 modifier (decision to perform surgery), the code is used in conjunction with 90-day global period (major) procedures, but not for (minor) procedures associated with a zero- or 10-day global period. In a resident supervision situation, CMS uses the term “minor” in a different way. The guidance regarding resident supervision issued by CMS is as follows: “For procedures that take only a few minutes (five minutes or less) to complete, e.g., simple suture, and involve relatively little decision-making once the need for the operation is determined, the teaching surgeon must be present for the entire procedure in order to bill for the procedure.” (This policy can be viewed at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/RC2303CP.pdf.) [pagebreak]

Many procedures with a 10-day global period take longer than five minutes to perform, and require significant decision-making after the need for the procedure was determined. For such procedures, the supervising attending physician must be present for the key and critical portion(s) of the procedure, but does not need to be present for the entire procedure.

Example 1:

You evaluate a patient with a large, ill-defined pearly plaque on the temple. A frozen section confirms a diagnosis of basal cell carcinoma. After an extensive examination, history, and discussion of the patient’s comorbidities, you determine that Mohs excision is appropriate. You clear the tumor by Mohs surgery and repair the defect with an adjacent tissue transfer.

The biopsy (11100-59) and frozen section pathology (88331-59) should be reported in addition to the Mohs surgery and the closure, if the lesion had not been biopsied previously (within the past 60 days or if biopsy was performed within the past 60 days and the histopathologic report cannot easily be obtained), the biopsy was interpreted prior to the definitive procedure, and the interpretation determined the subsequent procedure. In addition, depending on the documented cognitive services, it would probably be appropriate to code for E/M services and append the 57 modifier if you have not evaluated this patient previously. [pagebreak]

Medicare recognizes modifier 57 to indicate E/M services related to the decision to perform a medically necessary procedure associated with a 90-day global period. Mohs has a zero-day global period, but the adjacent tissue transfer is a “major” procedure with a 90-day global period. Medicare carriers have issued guidance that this modifier should not be used with procedures with a zero- or 10-day global period as they consider the decision to perform those procedures to be part of the usual pre-operative services bundled with the payment for those procedures. It should also be noted that modifier 57 should typically not be reported for prescheduled surgeries, as the decision to perform those was already reached in advance.

Example 2:

At a teaching hospital emergency department, you evaluate a patient with a very small laceration. You help the resident place a simple suture to ensure good wound approximation. It takes three minutes.

As this is a short procedure, lasting less than five minutes, that required little independent decision-making, it is appropriate that you are present for the entire procedure.

Example 3:

At a teaching hospital, you are asked to supervise two basal cell excisions simultaneously. Both require undermining and layered closure and last half an hour each. You move between the two rooms, making sure that you are present for the key and critical portions of each procedure.

As these are both longer procedures, lasting more than five minutes, that require significant independent decision-making during the procedure, it is appropriate that you are present for the “key and critical” portions of each procedure. Therefore, the “key and critical” portions may not take place at the same time. When all of the key portions of the initial procedure have been completed, then the physician can become involved in the second procedure.