Coding Guidelines for Surgical Procedures
Multiple Surgeries
Multiple surgeries are separate procedures performed by a physician on the same patient at the same operative session or on the same day. Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. Intraoperative services, incidental surgeries, or components of surgeries will not be separately reimbursed.
Reimbursement is based on teh following guidelines for multiple surgical procedures:
100% of the allowance for the highest valued procedure.
50% of the allowance for the second through the fifth highest level procedures.
The regular multiple surgery rules, as referenced above, will be applied to the procedure codes below when billed for the same beneficiary on the same day, by the same physician.
These pricing rules apply to dermatology services:
100% of the allowance for the highest valued procedure.
50% of the allowance for the remaining procedures.
When more than five procedures are performed, reimbursement for the sixth and/or subsequent procedures will be reviewed on an individual consideration basis. Operative notes should be submitted with the claim when five or more surgical procedures are performed during the same operative session.
If you report modifier 51 on claims, follow the guidelines below:
Report the highest procedure.
Report any additional surgical procedures with modifier 51.
Example:
If you are billing for a repair of a rotator cuff (Code 23412), and a ligament release (Code 23415), and a claviculectomy (Code 23120), report the codes as follows:
23412
23415 - 51
23120 - 51
If a surgeon of different specialties are each performing a different procedure (with specific CPT codes) multiple surgery rules do not apply. If one of the surgeons performs multiple procedures, the multiple surgery rules apply to that physician’s services.
Global surgical package
The payment for a surgical procedure, includes a standard package of preoperative, intraoperative, and postoperative services. The preoperative period included in the global fee for major surgery is 1 day. The postoperative period for major surgery is 90 days. The postoperative period for minor surgery is either 0 or 10 days depending on the procedure. For endoscopic procedures (except procedures requiring an incision), there is no postoperative period.
The Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery. The services included in the global surgical package may be furnished in any setting. Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon, However, critical care services (99291 and 99292) are payable separately in some situations.
The following services are included in the payment amount for a global surgery:
Preoperative visits - preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures.
Intraoperative services - Intraoperative services that are normally a usual and necessary part of a surgical procedure.
Complication following surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room.
Postoperative visits - Follow-up visits within the postoperative period of the surgery that are related to recovery from the surgery.
Postsurgical pain management - By the surgeon.
Supplies
Miscellaneous services - Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; changes and removal of tracheostomy tubes.
The following services are not included in the payment amount for a global surgery:
The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.
Services of other physicians, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record.
Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complication of the surgery.
Treatment for the underlying condition or and added course of treatment which is not part of the normal recovery from surgery.
Diagnostic tests and procedures, including diagnostic radiological procedures.
Clearly distinct surgical procedures during the postoperative period, which are not re-operations or treatment for complications (a new postoperative period begins with the subsequent procedure). This includes procedures done in 2 or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. Examples of this are procedures to diagnose and treat epilepsy (codes 61533-61536, 61539, 61541 and 61543), which may be performed in succession within 90 days of each other.
Treatment for postoperative complications requiring a return to the OR (operating room). An OR for this purpose is a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).
If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.
For certain services performed in a physician’s office.
Immunotherapy management for organ transplants.
Critical care services (codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.
For minor surgeries and endoscopies, the Medicare program will not pay separately for an evaluation and management service on the same day as a minor surgery or endoscopy, unless a significant, separately identifiable service is also performed, for example, an initial consultation or initial new patient visit. As stated earlier, there is no postoperative period for endoscopic procedures (unless an incision is required) and minor surgical procedures have postoperative period of 0 or 10 days, based on the procedure.
Splitting post-operative care
Specific billing guidelines must be followed when the surgical procedure and the post-operative care is split between different physicians.
Modifiers 54 and 55 are used to indicate that two different physicians are rendering the surgical care and post-operative management services. The physician who is rendering the one-day preoperative care, the intraoperative services, and any in-hospital visits bills his/her services with the date of the surgery, the procedure code for the surgery and a 54 modifier to indicate that the bill is reflective only for the surgical care.
The physician rendering the postoperative, out of hospital care associated with a given surgical procedure should bill for his/her services with the date of the surgery, the procedure code for the surgery, and a 55 modifier. If the surgeon also cares for the patient for some period following discharge, the surgeon should bill the surgery with a 55 modifier and indicate the portion of the post-op care provided in addition to the surgery with a 54 modifier (to indicate the intra-operative service).
In those cases where the postoperative care is “split” between physicians, the billing for the postoperative care should be reported as follows:
Report the date of service using the date of surgical procedure.
Report the procedure code for the surgical procedure, followed by a modifier 55.
Report the date postoperative care began and ended along with the number of postoperative care days provided in the narrative field on electronic claims, or block 19 on the CMS-1500 claim form.
Both the surgeon and the physician(s) providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical records. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he/she assumes care of the patient.
Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same procedure code, with the services distinguished by the use of the appropriate modifier.
Bilateral procedures
Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day. CMS has defined codes subject to the bilateral payment rule. Payment for claims reporting bilateral procedures is 150% of the fee schedule amount. The limiting charge is 115% of that amount.
Procedure codes containing the terms “bilateral” or “unilateral or bilateral” in their definitions are not subject to bilateral pricing. Payment for these services is 100% of the fee schedule for a surgical code. Procedure codes with terminology indicative of unilateral or bilateral services, as in code 27395 (lengthening of hamstring tendon; multiple, bilateral) or code 52290 (cystourethroscopy; with ureteral meatotomy, unilateral or bilateral) cannot be reported with the bilateral procedure code modifier 50 since the terminology for the code identifies the service as bilateral.
Certain procedures are not applicable to the 150% payment rule for bilateral procedures. Payment is 100% of the fee schedule for each side, e.g. codes 99225 and 99226. When performed bilaterally, report the codes with modifiers RT-LT or 50 to ensure proper payment.
Reporting guideline:
Report the procedure code with modifier 50.
Report a one in the number of services field.
For example, if you bill a bilateral mastectomy, report the service as a single line item: 19303 - 50
Assistant at Surgery
Some surgical procedures require a primary surgeon and an assistant surgeon. Payment will not be made for the services of assistants at surgery furnished in a teaching hospital which has a training program related to the medical specialty required for the surgical procedure and has a qualified resident available to perform the service.
Payment for an assistant surgeon is limited to 16% of the fee schedule amount for the surgical procedure. The limiting charge is 115% of the assistant surgeon’s fee schedule amount.
Additionally, the correct payment amount for assistant-at-surgery services furnished by PAs, NPs, and CNSs is 80% of the lesser of the actual charge or, 85% of 16% of what a physician is paid under the MPFS for surgical services.
Reporting guidelines:
Services for an assistant-at-surgery must be reported with one of the following modifiers as appropriate to the situation:
Modifier 80 - Report this modifier when the services are performed in a non-teaching setting or in a teaching setting when a resident was available, but the surgeon opted not to use the resident. In the latter case, the service is generally not covered by Medicare unless the following circumstances exist and are reported on the claim form:
Primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative, or postoperative cares of his/her patients.
Exceptional medical circumstances existed, e.g. emergency, life-threatening situations such as multiple traumatic injuries requiring immediate treatment.
Modifier 81 - Minimum assistant surgeon: Minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.
Modifier 82 - Report this modifier when there is no qualified resident surgeon available or when the services are performed in a teaching hospital that does not have an approved training program related to the medical specialty required for the surgical procedure.
Modifier AS - Report this modifier when a physician assistant, nurse practitioner, or clinical nurse specialists serves as assistant at surgery.
If you need any assistance or have questions regarding your surgical billing, contact Mediclaim Services Inc. and they will be glad to assist you in coding your surgical procedures. Proceed to our website www.mediclaimservices.com and click on “Ask us questions”.