Tuesday, August 30, 2016

Prepayment Edits to Detect Separate Billing of Services Included in the Global Package


In addition to the correct coding edits, A/B MACs (B) must be capable of detecting certain other services included in the payment for a major or minor surgery or for an endoscopy. On a prepayment basis, A/B MACs (B) identify the services that meet the following conditions:

• Preoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure; or

• Same day or postoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure or endoscopy;
and -

• Services that were furnished within the prescribed global period of the surgical procedure;

• Services that are billed without modifier “-78,” “-79,” “-24,” “25,” or “-57” or are billed with modifier “-24” but without the required documentation; and

• Services that are billed with the same provider or group number as the surgical procedure or endoscopy. Also, edit for any visits billed separately during the postoperative period without modifier “-24” by a physician who billed for the postoperative care only with modifier “-55.”

A/B MACs (B) use the following evaluation and management codes in establishing edits for visits included in the global package. CPT codes 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99271, 99272, 99273, 99274, and 99275 have been transferred from the excluded category and are now included in the global surgery edits.


Evaluation and Management Codes for A/B MAC (B) Edits

92012
92014
99211
99212
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99261
99262
99263
99271
99272
99273
99274
99275
99291
99292
99301
99302
99303
99311
99312
99313
99315
99316
99331
99332
99333
99347
99348
99349
99350
99374
99375
99377
99378


NOTE: In order for codes 99291 or 99292 to be paid for services furnished during the preoperative or postoperative period, modifier “-25” or “-24,” respectively, must be used to indicate that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed.

If a surgeon is admitting a patient to a nursing facility for a condition not related to the global surgical procedure, the physician should bill for the nursing facility admission and care with a “-24” modifier and appropriate documentation. If a surgeon is admitting a patient to a nursing facility and the patient’s admission to that facility relates to the global surgical procedure, the nursing facility admission and any services related to the global surgical procedure are included in the global surgery fee.


Services billed with the modifier “-25,” “-57,” “-58,” “-78,” or “-79.”

Exceptions

See §§40.2.A.8, 40.2.A.9, and 40.4.A for instances where prepayment review is required for modifier “-25.” In addition, prepayment review is necessary for CPT codes 90935, 90937, 90945, and 90947 when a visit and modifier “-25” are billed with these services


Exclude the following codes from the prepayment edits required in §40.3.B.
92002
92004
99201
99202
99203
99204
99205
99281
99282
99283
99284
99285
99321
99322
99323
99341
99342
99343
99344
99345

Friday, August 26, 2016

Evaluation and Management Service Resulting in the Initial Decision to Perform Surgery


Evaluation and management services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery and, therefore, may be billed and paid separately.

In addition to the CPT evaluation and management code, modifier “-57” (decision for surgery) is used to identify a visit which results in the initial decision to perform surgery. (Modifier “-QI” was used for dates of service prior to January 1, 1994.)

If evaluation and management services occur on the day of surgery, the physician bills using modifier “-57,” not “-25.” The “-57” modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.



Return Trips to the Operating Room During the Postoperative Period

When treatment for complications requires a return trip to the operating room, physicians must bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, use the unspecified procedure code in the correct series, i.e., 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated.

In addition to the CPT code, physicians use CPT modifier “-78” for these return trips (return to the operating room for a related procedure during a postoperative period.)
The physician may also need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first procedure and requires the use of the operating room, this circumstance may be reported by adding the modifier “-78” to the related procedure.


NOTE: The CPT definition for this modifier does not limit its use to treatment for complications.

Monday, August 22, 2016

Billing Guide for Bilateral surgeries with example


A. General

Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day.

The terminology for some procedure codes includes the terms “bilateral” (e.g., code 27395; Lengthening of the hamstring tendon; multiple, bilateral.) or “unilateral or bilateral” (e.g., code 52290; cystourethroscopy; with ureteral meatotomy, unilateral or bilateral). The payment adjustment rules for bilateral surgeries do not apply to procedures identified by CPT as “bilateral” or “unilateral or bilateral” since the fee schedule reflects any additional work required for bilateral surgeries.
Field 22 of the MFSDB indicates whether the payment adjustment rules apply to a surgical procedure.



B. Billing Instructions for Bilateral Surgeries

If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral), physicians must report the procedure with modifier “-50.” They report such procedures as a single line item. (NOTE: This differs from the CPT coding guidelines which indicate that bilateral procedures should be billed as two line items.)
If a procedure is identified by the terminology as bilateral (or unilateral or bilateral), as in codes 27395 and 52290, physicians do not report the procedure with modifier “-50.”



C. Claims Processing System Requirements

Carriers must be able to:

1. Identify bilateral surgeries by the presence on the claim form or electronic submission of the “-50” modifier or of the same code on separate lines reported once with modifier “-LT” and once with modifier “-RT”;

2. Access Field 34 or 35 of the MFSDB to determine the Medicare payment amount;

3. Access Field 22 of the MFSDB:

• If Field 22 contains an indicator of “0,” “2,” or “3,” the payment adjustment rules for bilateral surgeries do not apply. Base payment on the lower of the billed amount or 100 percent of the fee schedule amount (Field 34 or 35) unless other payment adjustment rules apply.

NOTE: Some codes which have a bilateral indicator of “0” in the MFSDB may be performed more than once on a given day. These are services that would never be considered bilateral and thus should not be billed with modifier “-50.” Where such a code is billed on multiple line items or with more than 1 in the units field and carriers have determined that the code may be reported more than once, bypass the “0” bilateral indicator and refer to the multiple surgery field for pricing;

• If Field 22 contains an indicator of “1,” the standard adjustment rules apply. Base payment on the lower of the billed amount or 150 percent of the fee schedule amount (Field 34 or 35). (Multiply the payment amount in Field 34 or 35 for the surgery by 150 percent and round to the nearest cent.)

4. Apply the requirements §§40 - 40.4 on global surgeries to bilateral surgeries; and

5. Retain the “-50” modifier in history for any bilateral surgeries paid at the adjusted amount.

(NOTE: The “-50” modifier is not retained for surgeries which are bilateral by definition such as code 27395.)

Friday, August 19, 2016

Multiple surgery with Modifier 22


Ranking of Same Day Multiple Surgeries When One Surgery Has a “-22” Modifier and Additional Payment is Allowed


If the patient returns to the operating room after the initial operative session on the same day as a result of complications from the original surgery, the complications rules apply to each procedure required to treat the complications from the original surgery. The multiple surgery rules would not apply.

However, if the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for multiple
procedures that are required as a result of complications from the original surgery, the complications rules would apply. The multiple surgery rules would also not apply.

Multiple surgeries are defined as separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day.

Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. These intra-operative services, incidental surgeries, or components of more major surgeries are not separately billable.

Wednesday, August 17, 2016

Claim submission Guide for multiple surgeries with example


A. General

Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day.

Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. These intra-operative services, incidental surgeries, or components of more major surgeries are not separately billable. See Chapter 23 for a description of mandatory edits to prevent separate payment for those procedures. Major surgical procedures are determined based on the MFSDB approved amount and not on the submitted amount from the providers. The major surgery, as based on the MFSDB, may or may not be the one with the larger submitted amount.

Also, see subsection D below for a description of the standard payment policy on multiple surgeries. However, these standard payment rules are not appropriate for certain procedures. Field 21 of the MFSDB indicates whether the standard payment policy rules apply to a multiple surgery, or whether special payment rules apply. Site of service payment adjustments (codes with an indicator of “1” in Field 27 of the MFSDB) should be applied before multiple surgery payment adjustments.


B. Billing Instructions

The following procedures apply when billing for multiple surgeries by the same physician on the same day.

• Report the more major surgical procedure without the multiple procedures modifier “-51.”

• Report additional surgical procedures performed by the surgeon on the same day with modifier “-51.”

There may be instances in which two or more physicians each perform distinctly different, unrelated surgeries on the same patient on the same day (e.g., in some multiple trauma cases). When this occurs, the payment adjustment rules for multiple surgeries may not be appropriate. In such cases, the physician does not use modifier “-51” unless one of the surgeons individually performs multiple surgeries.



C. Carrier Claims Processing System Requirements

Carriers must be able to:

1. Identify multiple surgeries by both of the following methods:

• The presence on the claim form or electronic submission of the “-51” modifier; and

• The billing of more than one separately payable surgical procedure by the same physician performed on the same patient on the same day, whether on different lines or with a number greater than 1 in the units column on the claim form or inappropriately billed with modifier “-78” (i.e., after the global period has expired);

2. Access Field 34 of the MFSDB to determine the Medicare fee schedule payment amount for each surgery;

3. Access Field 21 for each procedure of the MFSDB to determine if the payment rules for multiple surgeries apply to any of the multiple surgeries billed on the same day;

4. If Field 21 for any of the multiple procedures contains an indicator of “0,” the multiple surgery rules do not apply to that procedure. Base payment on the lower of the billed amount or the fee schedule amount (Field 34 or 35) for each code unless other payment adjustment rules apply;

5. For dates of service prior to January 1, 1995, if Field 21 contains an indicator of “1,” the standard rules for pricing multiple surgeries apply (see items 6-8 below);

6. Rank the surgeries subject to the standard multiple surgery rules (indicator “1”) in descending order by the Medicare fee schedule amount;

7. Base payment for each ranked procedure on the lower of the billed amount, or:

• 100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure;

• 50 percent of the fee schedule amount for the second highest valued procedure; and

8. If more than five procedures are billed, pay for the first five according to the rules listed in 5, 6, and 7 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, “by report.” Payment determined on a “by report” basis for these codes should never be lower than 25 percent of the full payment amount;

9. For dates of service on or after January 1, 1995, new standard rules for pricing multiple surgeries apply. If Field 21 contains an indicator of “2,” these new standard rules apply (see items 10-12 below);

10. Rank the surgeries subject to the multiple surgery rules (indicator “2”) in descending order by the Medicare fee schedule amount;

11. Base payment for each ranked procedure (indicator “2”) on the lower of the billed amount:

• 100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure; and

• 50 percent of the fee schedule amount for the second through the fifth highest valued procedures; or

12. If more than five procedures with an indicator of “2” are billed, pay for the first five according to the rules listed in 9, 10, and 11 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, “by report.” Payment determined on a “by report” basis for these codes should never be lower than 50 percent of the full payment amount. Pay by the unit for services that are already reduced (e.g., 17003). Pay for 17340 only once per session, regardless of how many lesions were destroyed;

NOTE: For dates of service prior to January 1, 1995, the multiple surgery indicator of “2” indicated that special dermatology rules applied. The payment rules for these codes have not changed. The rules were expanded, however, to all codes that previously had a multiple surgery indicator of “1.” For dates of service prior to January 1, 1995, if a dermatological procedure with an indicator of “2” was billed with the “-51” modifier with other procedures that are not dermatological procedures (procedures with an indicator of “1” in Field 21), the standard multiple surgery rules applied. Pay no less than 50 percent for the dermatological procedures with an indicator of “2.” See §§40.6.C.6-8 for required actions.

13. If Field 21 contains an indicator of “3,” and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy. Access Field 31A of the MFSDB to determine the base endoscopy.



EXAMPLE

In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 percent for the highest valued procedure (45385) and 50 percent for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).

Carriers assume the following fee schedule amounts for these codes:

45378 - $255.40

45380 - $285.98

45385 - $374.56

Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14.

NOTE: If an endoscopic procedure with an indicator of “3” is billed with the “-51” modifier with other procedures that are not endoscopies (procedures with an indicator of “1” in Field 21), the standard multiple surgery rules apply.

14. Apply the following rules where endoscopies are performed on the same day as unrelated endoscopies or other surgical procedures:

• Two unrelated endoscopies (e.g., 46606 and 43217): Apply the usual multiple surgery rules;

• Two sets of unrelated endoscopies (e.g., 43202 and 43217; 46606 and 46608): Apply the special endoscopy rules to each series and then apply
the multiple surgery rules. Consider the total payment for each set of endoscopies as one service;

• Two related endoscopies and a third, unrelated procedure: Apply the special endoscopic rules to the related endoscopies, and, then apply the multiple surgery rules. Consider the total payment for the related endoscopies as one service and the unrelated endoscopy as another service.



15. If two or more multiple surgeries are of equal value, rank them in descending dollar order billed and base payment on the percentages listed above (i.e., 100 percent for the first billed procedure, 50 percent for the second, etc.);

16. If any of the multiple surgeries are bilateral surgeries, consider the bilateral procedure at 150 percent as one payment amount, rank this with the remaining procedures, and apply the appropriate multiple surgery reductions. See §40.7 for bilateral surgery payment instructions.);

17. Round all adjusted payment amounts to the nearest cent;

18. If some of the surgeries are subject to special rules while others are subject to the standard rules, automate pricing to the extent possible. If necessary, price manually;

19. In cases of multiple interventional radiological procedures, both the radiology code and the primary surgical code are paid at 100 percent of the fee schedule amount. The subsequent surgical procedures are paid at the standard multiple surgical percentages (50 percent, 50 percent, 50 percent and 50 percent);

20. Apply the requirements in §§40 on global surgeries to multiple surgeries;

21. Retain the “-51” modifier in history for any multiple surgeries paid at less than the full global amount; and

22. Follow the instructions on adjudicating surgery claims submitted with the “-22” modifier. Review documentation to determine if full payment should be made for those distinctly different, unrelated surgeries performed by different physicians on the same day.

Saturday, August 13, 2016

Global surgery denial code B15, CO 97, B20 AND MA130


Remittance Record

“Claim/service denied/reduced because this procedure/service is not paid separately.” (Reason Code B15. Group code CO 97)



2. Messages for Global Packages Split Between Two or More Physicians

When a physician furnishes only the pre- and intra-operative services, but bills for the entire package, the following statements on the MSN and remittance advice.

 “Payment has been reduced because a different doctor took care of you before and/or after the surgery. You should not be billed for this item or service. You do not have to pay this amount.”

“Charges denied/reduced because procedure/service was partially or fully furnished by another physician.” (Reason Code B20, Group Code CO B20)


3. Message for Procedure Codes With “ZZZ” Global Period Billed as Stand-Alone Procedures

When a physician bills for a surgery with a “ZZZ” global period without billing for another service, include one of the following statements on the MSN and remittance notice.
A/B MACs (B) include the following message on the MSN for claims:


This item or service was denied because information required to make payment was missing.” (CO 16)

 “Please ask your provider to submit a new, complete claim to us.”

(NOTE: Add on to other messages as appropriate).

16. When using 16, A/B MACs (B) should also use a claim remark code such as a return/reject code (MA 29MA 43, etc.) to show why claim rejected as incomplete.


Message for Payment Amount When Modifier “-22” Is Submitted Without Documentation

When a physician submits a claim with modifier “-22” but does not provide additional documentation, use the following or a similar remittance advice message:

9.7 - “We have asked your provider to resubmit the claim with the missing or correct information.” (NOTE: Add on to other messages as appropriate.) MA 130

Tuesday, August 9, 2016

Payment for Return Trips to the Operating Room for Treatment of Complications



When a CPT code billed with modifier “-78” describes the services involving a return trip to the operating room to deal with complications, A/B MACs (B) pay the value of the intra-operative services of the code that describes the treatment of the complications. Refer to Field 18 of the MFSDB to determine the percentage of the global package for the intra-operative services. The fee schedule amount (Field 34 or 35 of the MFSDB) is multiplied by this percentage and rounded to the nearest cent.

When a procedure with a “000” global period is billed with a modifier “-78,” representing a return trip to the operating room to deal with complications, A/B MACs (B) pay the full value for the procedure, since these codes have no pre-, post-, or intra-operative values.

When an unlisted procedure is billed because no code exists to describe the treatment for complications, A/B MACs (B) base payment on a maximum of 50 percent of the value of the intra-operative services originally performed. If multiple surgeries were originally performed, A/B MACs (B) base payment on no more than 50 percent of the value of the intra-operative services of the surgery for which the complications occurred. They multiply the fee schedule amount for the original surgery (Field 34 or 35) by the intra-operative percentage for the procedure (Field 18), and then multiply that figure by 50 percent to obtain the maximum payment amount.



[.50 X (fee schedule amount x intra-operative percentage)]. Round to the nearest cent.

If additional procedures are performed during the same operative session as the original surgery to treat complications which occurred during the original surgery, A/B MACs (B) pay the additional procedures as multiple surgeries. Only surgeries that require a return to the operating room are paid under the complications rules.

If the patient is returned to the operating room after the initial operative session, but on the same day as the original surgery for one or more additional procedures as a result of complications from the original surgery, the complications rules apply to each procedure required to treat the complications from the original surgery. The multiple surgery rules would not also apply.

If the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for multiple procedures that are required as a result of complications from the original surgery, the complications rules would apply. The multiple surgery rules would also not apply.
If the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for bilateral procedures that are required as a result of complications from the original surgery, the complication rules would apply. The bilateral rules would not apply.

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