Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1.
Definition of a global
surgical package.
Coding and payment for all surgical procedures is based on a
global surgical package as described in this part and part
5221.4020, subpart 2a, items O, P,
Q, and R. Physicians are not paid separately for visits or other services that
are included in the global package.
A.
To determine the global period for surgeries with a 090 global period in column
O, include the day immediately before the day of surgery, the day of surgery,
and the 90 days immediately following the day of surgery.
EXAMPLE: Date of surgery, September 10; preoperative period,
September 9; last day of global period, December 9.
To determine the global period for procedures with a 010 global
period in column O, count the day of surgery and the appropriate number of days
immediately following the date of surgery.
EXAMPLE: Date of surgery, January 5; last day of global period,
January 15.
The global period for procedures with a 000 global period
include only the services provided on the day of surgery.
B. Columns P, Q, and R of the Medicare
Relative Value tables incorporated by reference in part
5221.4005 designate the
percentages of the global package assigned to preoperative services,
intraoperative services, and postoperative services. These are used to
determine the percent of the maximum fee, established by the formula in part
5221.4020, subpart 1b, that is
paid to physicians providing one or more components of the global package.
EXAMPLE: For physicians who perform the surgery and furnish all
of the usual preoperative, intraoperative, and postoperative work the maximum
fee is 100 percent (the sum or the percentages in columns P, Q, and R) of the
maximum fee established by the formula in part
5221.4020, subpart 1b, for the
appropriate CPT code and any appropriate modifiers for the surgical procedure
only. Payment for physicians who furnish less than the full global package is
described in subpart 4.
Other subparts may affect coding and payment for services for
which a global period applies. Subpart 2 further defines services included in
the global surgical package. Subpart 3 further defines services not included in
the global surgical package. Subpart 4 governs coding and payment adjustment
for physicians furnishing less than the full global package. Subpart 5
specifies additional coding and payment requirements for multiple surgeries.
Subpart 6 specifies additional coding and payment requirements for bilateral
procedures. Subpart 7 specifies additional coding and payment requirements for
assistant-at-surgery. Subpart 8 specifies additional coding and payment
requirements for cosurgeons. Subpart 9 specifies additional coding and payment
requirements for team surgery.
Subp. 2.
Components of a global
surgical package.
The global surgical package includes coding and payment
instructions 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, for example, in hospitals,
ambulatory surgical centers, outpatient hospital surgical centers, and
physicians' offices. Visits to a patient in an intensive care or critical care
unit are also included if made by the surgeon. However, certain critical care
services identified by CPT codes 99291 and 99292 are payable separately as
specified in subpart 3, item L. Included in the global surgical package
are:
A. preoperative visits as
follows:
(1) preoperative visits beginning
with the day before the day of surgery for procedures with a global period of
090 days except that the evaluation and management service to determine the
need for surgery is separately coded and paid in accordance with subpart 3,
item A, subitem (1), even if the evaluation and management service is the day
before or the day of surgery; and
(2) preoperative visits the day of surgery
for procedures with a global period of 000 or 010 days unless a significant
separately identifiable evaluation and management service is performed as
described in subpart 3, item A, subitem (2);
B. intraoperative services which include
services that are normally a usual and necessary part of a surgical
procedure;
C. 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. Subpart 3, item G, governs services for
postoperative complications which require a return trip to the operating
room;
D. postoperative visits which
include follow-up visits during the global period of the surgery that are
related to recovery from the surgery;
E. postsurgical pain management by the
surgeon;
F. supplies, except for
those noted in subpart 3, item I; and
G. miscellaneous services 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, and changes and removal of
tracheostomy tubes.
Subp.
3.
Services not included in global surgical package.
The services listed in items A to O are not included in the
global surgical package. These services may be coded and paid for separately.
Physicians must use appropriate modifiers as set forth in this subpart.
A. The initial consultation or evaluation of
the problem by the surgeon to determine the need for a surgical procedure is
coded and paid as specified in subitems (1) and (2):
(1) for services with a global period of 090
days, a separate payment is allowed for the appropriate level of evaluation and
management service. This circumstance must be coded by adding CPT modifier 57
to the appropriate level of evaluation and management service; or
(2) for services with a global period of 000
or 010, and endoscopies, the initial consultation or evaluation services by the
same physician on the same day as the procedure, are included in the payment
for the procedure, unless a significant, separately identifiable service is
also performed. For example, an evaluation and management service on the same
day could be properly billed in addition to suturing a scalp wound if a full
neurological examination is made for a patient with head trauma. Payment for an
evaluation and management service is not appropriate if the physician only
identified the need for sutures and confirmed allergy and immunization status.
The physician must document in the medical record that the patient's condition
required a significant, separately identifiable evaluation and management
service above and beyond the usual preoperative and postoperative care
associated with the procedure or service that was performed. This circumstance
must be coded by adding CPT modifier 25 to the appropriate level of evaluation
and management service.
B. Services of other physicians are not
included in the global surgical package and are separately coded and paid as
follows:
(1) preoperative physical examination
and postdischarge services of a physician other than the surgeon are coded by
the appropriate evaluation and management code and are paid separately. No
modifiers are necessary;
(2)
physicians who provide follow-up services for procedures with a global period
of 000 or 010 that were initially performed in emergency departments may charge
the appropriate level of office visit code and are paid separately. The
physician who performs the emergency room service codes for the surgical
procedure without a modifier;
(3)
if the services of a physician other than the surgeon are required during a
postoperative period for an underlying condition or medical complication, the
other physician codes the appropriate evaluation and management service and is
paid separately. No modifiers are necessary. An example is a cardiologist who
manages underlying cardiovascular conditions of a patient; and
(4) where the surgeon and another physician
or physicians agree to transfer care otherwise included in the global period,
coding and payment are governed by subpart 4.
C. Visits unrelated to the diagnosis for
which the surgical procedure is performed, unless the visits occur due to
complica tions of the surgery, are not included in the global surgical package
and are separately payable. Physicians must use the following modifiers if
appropriate:
(1) CPT modifier 79 identifies
an unrelated procedure by the same physician during a postoperative period. The
physician must document that the performance of a procedure during a
postoperative period was unrelated to the original procedure; and
(2) CPT modifier 24 identifies an unrelated
evaluation and management service by the same physician during a postoperative
period. This circumstance must be coded by adding CPT modifier 24 to the
appropriate level of evaluation and management service. The physician must
document that an evaluation and management service was performed during the
postoperative period of an unrelated procedure. An ICD-9-CM code that clearly
indicates that the reason for the encounter was unrelated to the surgery is
acceptable documentation. For treatment on or after October 1, 2015, an
ICD-10-CM code that clearly indicates that the reason for the encounter was
unrelated to the surgery is acceptable documentation.
D. Treatment for the underlying condition or
an added course of treatment which is not part of normal recovery from surgery
is not included in the global surgical package and is separately payable.
Complications from the surgical procedure are governed by item G and subpart 2,
item C.
E. Diagnostic tests and
procedures, including diagnostic radiological procedures and diagnostic
biopsies, are not included in the global surgical package and are separately
coded and payable. If a diagnostic biopsy with a ten-day global period precedes
a major surgery on the same day or in the ten-day period, the major surgery is
payable separately.
F. Clearly
distinct surgical procedures during the postoperative period which are not
reoperations for complications (reoperations for complications are governed by
item G) are not included in the global surgical package and are separately
payable. This includes procedures done in two 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, 61534-61536, 61539, 61541, and 61543, which may be
performed in succession within 90 days of each other.
CPT modifier 58 must be used to code for staged or related
surgical procedures done during the global period of the first procedure. The
global period for the staged or subsequent procedures is separate from the
global period for the proceeding procedure.
G. Treatment for postoperative complications
which requires a return trip to the operating room is not included in the
global surgical package and is separately coded and paid as specified in this
item. This additional procedure is referred to as a reoperation.
"Operating room," for this purpose, is defined as a place of
service specifically equipped and staffed for the sole purpose of performing
procedures. Operating room includes a cardiac catheterization suite, laser
suite, and endoscopy suite. It does not include a patient's room, minor
treatment room, recovery room, or intensive care unit, unless the patient's
condition was so critical there would be insufficient time for transportation
to an operating room.
(1) When coding
for treatment for postoperative complications for services with a global period
of 090 or 010 days which requires a return trip to the operating room, as
defined in this item, physicians must code the CPT code that describes the
procedures performed during the return trip as follows:
(a) Some reoperations have been assigned
separate, distinct reoperation CPT procedure codes and RVUs. The maximum fee
for these procedures is calculated using the RVUs for the coded reoperation and
the formula in part
5221.4020.
(b) Reoperations that have not been assigned
separate, distinct reoperation CPT codes must be identified on the bill with
the CPT procedure code that describes the procedure or treatment for the
complication plus CPT modifier 78 which indicates a return to the operating
room for a related procedure during the global period. The CPT procedure code
may be the one used for the original procedure when the identical procedure is
repeated or another CPT procedure code which describes the actual procedure or
service performed.
The maximum fee for a reoperation procedure without a separate
distinct reoperation CPT code is the maximum fee established by the formula in
part
5221.4020, subpart 1b, multiplied
by the intraoperative percentage listed in column Q.
(c) When no CPT code exists to describe the
treatment for complications, use an unlisted surgical procedure code plus CPT
modifier 78 which indicates a return to the operating room for a related
procedure during the global period. The maximum fee for the reoperation is the
maximum fee for the original procedure established by the formula in part
5221.4020, subpart 1b, multiplied
by 50 percent of the intraoperative percent listed in column Q.
(2) When coding for treatment for
postoperative complications for a procedure with a 000 global period,
physicians must use CPT modifier 78 which indicates a return trip to the
operating room for a related procedure during the postoperative global period.
The full value for the repeat procedure is paid according to the formula in
part
5221.4020.
(3) If additional procedures are performed
during the same operative session as the original surgery to treat
complications which occurred during the original surgery, the additional
procedures are coded and paid as multiple surgeries as specified in subpart 5.
Only surgeries that require a return to the operating room due to complications
from the original surgery are coded and paid as specified in subitems (1) and
(2).
(4) If the patient is returned
to the operating room after the initial operative session and during the
postoperative global surgery period of the original surgery, for one or more
additional procedures as a result of complications from the original surgery,
each procedure required to treat the complications from the original surgery is
paid as specified in subitem (1) or (2).
The multiple surgery rules under subpart 5 do not also apply.
The original operation session and the reoperation session are separate and
distinct surgical sessions. The reoperation is not considered a multiple
surgery, as described in subpart 5, of the original operation. If during the
reoperation session multiple surgeries are performed, the additional surgeries
are not governed by the multiple surgery payment rules in subpart 5 but are
governed by subitems (1) and (2).
(5) If the patient is returned to the
operating room during the postoperative global surgery 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,
subitems (1) to (4) apply. The bilateral rules in subpart 6 and part
5221.4020, subpart 2a, item T, do
not apply.
H. If a less
extensive procedure fails, and a more extensive procedure is required, the
second procedure is coded and paid separately.
I. Surgical trays are not paid separately.
Payment for the surgical tray is included in the RVUs for the surgical
procedure.
J. Splints, casting, and
take-home supplies are coded and paid separately.
K. Immunosuppressive therapy for organ
transplants is coded and paid separately.
L. Critical care services (CPT 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,
provided during a global surgical period, are coded and paid
separately.
M. Except as provided
in part
5221.0410, subpart 7, item A, the
physician may separately bill a reasonable amount for supplementary reports and
services directly related to the employee's ability to return to work, fitness
for job offers, and opinions as to whether or not the condition was related to
a work-related injury. Coding and payment for these services is governed by
parts
5221.0410, subpart 7; 5221.0420,
subpart 3; and 5221.0500, subpart 2.
N. The global surgical package does not
apply, and separate coding and payment is allowed, for an initial service that
meets both of the conditions in subitems (1) and (2):
(1) the service is for initial care only to
afford comfort to a patient or to stabilize or protect a fracture, dislocation,
or other injury; and
(2) subsequent
restorative treatment, such as surgical repair or reduction of a fracture or
joint dislocation, is expected to be performed by a physician other than the
physician rendering the initial care only.
O. Surgeries for which services performed are
significantly greater or more complex than usually required must be coded with
CPT modifier 22 added to the CPT code for the procedure. Additional
requirements for use of this modifier are in subitems (1) to (5).
(1) This modifier may only be used where
circumstances create a more complex procedure such as congenital or
developmental disorders of the anatomy, multiple fractures of the same long
bone, coexisting disease, when there has been previous surgery on the same body
part or where there is a significant amount of scar tissue.
(2) This modifier may only be reported with
procedure codes that have a global period of 000, 010, or 090 days.
(3) Physicians must provide:
(a) a concise statement about how the service
is significantly more complex than usually required; and
(b) an operative report with the
claim.
(4) The maximum
fee for a surgical procedure that has satisfied all of the requirements for use
of CPT modifier 22 is up to 125 percent of the maximum fee calculated under
part
5221.4020, subpart 1b, for that
CPT code.
(5) CPT modifier 22 is
not used to report additional procedures that are performed during the same
operative session as the original surgery to treat complications which occurred
during the original surgery. Additional procedures to treat complications which
occurred during surgery are governed by subpart 5.
Subp. 4.
Physicians
furnishing less than full global package.
There are occasions when more than one physician provides
services included in the global surgical package. It may be the case that the
physician who performs the surgical procedure does not furnish the follow-up
care. Payment for the postoperative and postdischarge care is split between two
or more physicians where the physicians agree on the transfer of care. Coding
and payment requirements for physicians furnishing less than the full global
package are:
A. When more than one
physician furnishes services that are included in the global surgical package,
the maximum fee for each physician is a percentage of the total maximum fee
established by the formula in part
5221.4020, subpart 1b, multiplied
by the sum of the percentages in columns P, Q, and R for the type of operative
service provided. For example, the maximum fee for a physician who performs the
preoperative and postoperative services, but not the intraoperative service,
would be as follows:
| The maximum fee for the CPT code established by the formula
in part
5221.4020, subpart 1b |
* |
(the percentage in column P plus the percentage in column
R) |
B.
Where physicians agree on the transfer of care during the global period, they
must add the appropriate CPT modifier to the surgical procedure code:
(1) CPT modifier 54 for surgical care only;
or
(2) CPT modifier 55 for
postoperative management only.
C. Physicians who share postoperative
management with another physician must submit additional information showing
when they assumed and relinquished responsibility for the postoperative care.
If the physician who performed the surgery relinquishes care at the time of
discharge, the physician need only show the date of surgery when billing with
CPT modifier 54.
However, if the surgeon also cares for the patient for some
period following discharge, the surgeon must show the date of surgery and the
date on which postoperative care was relinquished to another physician. The
physician providing the remaining postoperative care must show the date care
was assumed.
D. If a
surgeon performs a procedure with a global period of 010 or 090 days, and cares
for the patient until time of discharge from a hospital or ambulatory surgical
center, the maximum fee for this surgeon's services is:
| The maximum fee for the CPT code established by the formula
in part
5221.4020, subpart 1b |
* |
(the percentage in column P plus the percentage in column
Q) |
Modifier 54 is used to identify these services.
E. If a health care provider who
did not perform the surgery assumes surgical follow-up care of a patient after
discharge from the hospital or ambulatory surgical center, then the maximum fee
for this practitioner's services is:
| The maximum fee for the CPT code established by the formula
in part
5221.4020, subpart 1b |
* |
(the percentage in column R) |
CPT modifier 55 is used to identify these services.
F. If several health care
providers furnish postoperative care, the maximum fee for the postoperative
period is divided among the practitioners based on the number of days for which
each health care provider was primarily responsible for care of the patient.
CPT modifier 55 (for postoperative management only) is used to identify
postoperative services furnished by more than one provider.
G. If the providers have agreed to a payment
distribution of the global fee that differs from the distributions set forth in
items D to F, then payments will be made accordingly, if the agreed-upon
distribution is documented and explained on the bill for the procedure and is
not prohibited by Minnesota Statutes, section
147.091,
subdivision 1, paragraph (p).
Subp.
5.
Coding and payment for multiple surgeries and procedures.
Part
5221.4020, subpart 2a, item S, and
column S in the tables incorporated by reference in part
5221.4005, subpart 1, item A,
describe codes subject to the multiple procedures payment restrictions.
Multiple surgeries are separate surgeries performed by a single physician on
the same patient at the same operative session or on the same day for which
separate payment may be allowed.
A.
The coding requirements in subitems (1) and (2) apply to multiple surgeries
that have an indicator of 2 or 3 in column S by the same physician on the same
day as specified in items D and E:
(1) the
surgical procedure with the highest maximum fee calculated according to part
5221.4020, subpart 1b, is reported
without the multiple procedures CPT modifier 51;
(2) the additional surgical procedures
performed are reported with CPT modifier 51.
B. There may be instances in which two or
more physicians each perform distinctly different, unrelated surgeries on the
same patient on the same day, for example, in some multiple trauma cases. When
this occurs, CPT modifier 51 is not used and the multiple procedure payment
reductions do not apply unless one of the surgeons individually performs
multiple surgeries.
C. If any of
the multiple surgeries are bilateral or cosurgeries, first determine the
allowed amount for the procedure as specified in subpart 6 or 8, next rank this
amount with the remaining procedures, and finally, apply the appropriate
multiple surgery payment reductions as specified in items D and E.
D. For procedures with an indicator of 2 in
column S, if the procedures are reported on the same day as another procedure
with an indicator of 2, the maximum fee for the procedure with the highest
amount calculated under part
5221.4020, subpart 1b, is paid at
100 percent of the amount calculated, and the maximum fee for each additional
procedure with an indicator of 2 is paid at 50 percent of the amount calculated
under part
5221.4020, subpart 1b.
E. For procedures with an indicator of 3 in
column S, the multiple endoscopy payment rules apply if the procedure is billed
with another endoscopy with the same base code. Column X lists the endoscopic
base code for each code in column A with a multiple surgery indicator of 3. For
purposes of this item, the term "endoscopy" also includes arthroscopy
procedures. If an endoscopy procedure is performed on the same day as another
endoscopy procedure within the same base code, the maximum fee for the
procedure with the highest amount calculated under part
5221.4020, subpart 1b, is 100
percent of the amount calculated. The maximum fee for every other procedure
with the same base code is reduced by the amount calculated under part
5221.4020, subpart 1b, for the
endobase code in column X. No separate payment is made for the endobase
procedure when other endoscopy procedures with the same base code are performed
on the same day.
(1) For example, if column S
has an indicator of 3 for multiple endoscopic procedures, and column X lists
the endoscopic base code (endobase) as 29805, with a maximum allowable fee (for
illustrative purposes) of $400 calculated according to the formula in part
5221.4020, subpart 1b, the maximum
amount payable would be as follows:
| Procedures performed (code listed in column A) |
Maximum fee under formula in part
5221.4020, subpart 1b (for
illustrative purposes) | Maximum fee under part
5221.4035, subpart 5, item E (for
illustrative purposes) | Description |
| 29827 | $950 | $950 | Pay 100
percent of the maximum fee for the procedure with the highest maximum fee under
formula in part
5221.4020, subpart 1b |
| 29828 | $790 | $390 | Reduce the
maximum fee by $400 (the maximum fee for endobase code 29805)$790 - $400 =
$390 |
| 29823 | $540 | $140 | Reduce the
maximum fee by $400 (the maximum fee for endobase code 29805)$540 - $400 =
$140 |
Total allowable payment: $1480
(2) For two unrelated series of endoscopy
procedures, the endoscopy pricing rule is applied first to all codes with the
same base code in column X. The multiple surgery pricing rule as depicted by
indicator 2 is then applied as follows. The maximum fee for the codes in the
series with the highest total amount calculated under this item is 100 percent
of the amount calculated. The maximum fee for codes in the series with the
lower total amount calculated under this item is 50 percent of the amount
calculated.
(3) Endoscopy
procedures billed with other surgery procedures. All procedures subject to the
multiple surgery pricing rule are ranked from highest to lowest to determine
which codes, or groups of codes, are allowed at 100 percent or 50 percent of
the their calculated maximum value. If two or more of the billed codes belong
to the same endoscopy family, the endoscopy pricing rule is applied first, and
the total value of the endoscopy series is used in the
array.
F. For diagnostic
imaging procedures with an indicator of 4 in column S, special rules for the
technical component (TC) and professional component (PC) of diagnostic imaging
procedures apply if the procedure is billed with another diagnostic imaging
procedure with indicator 88 in column AB. If the procedure is furnished by the
same provider, or different providers in the same group practice, to the same
patient in the same session on the same day as another procedure with indicator
88, the procedures must be ranked according to the maximum fee for the
technical component and professional component, calculated according to the
formula in part
5221.4020, subpart 1b. The
technical component with the highest maximum fee is paid at 100 percent, and
the technical component of each subsequent procedure is paid at 50 percent. The
professional component with the highest maximum fee is paid at 100 percent, and
the professional component of each subsequent procedure is paid at 95 percent.
For example (for illustrative purposes):
|
|
Unadjusted Maximum Fee, Procedure 1 |
Unadjusted Maximum Fee, Procedure 2 |
Total Adjusted Maximum Fee |
Calculation of Total Adjusted Maximum Fee |
| PC |
$100 |
$80 |
$160 |
$176 ($100 + (.95 x $80)) |
| TC |
$500 |
$400 |
$700 |
$700 ($500 + (.50 x $400)) |
| Global |
$600 |
$480 |
$860 ($600 + (.75 x $80) + (.50 x $400)) |
$876 ($600 + (.95 x $80) + (.50 x $400)) |
G.
For procedures with an indicator of 5 in column S that are not also listed in
part
5221.4050, subpart 2d, or
5221.4060, subpart 2d, the rules in subitems (1) to (4) apply to establish the
maximum fee according to the formula in part
5221.4020, subpart 1b.
(1) When more than one unit or procedure with
an indicator of 5 is provided to the same patient on the same day, full payment
is made for the unit or procedure with the highest practice expense (PE)
RVU.
(2) For subsequent units and
procedures furnished to the same patient on the same day, full payment is made
for the work and malpractice expense RVUs and 50 percent payment is made for
the practice expense RVU.
(3) For
therapy services furnished by a provider, a group practice, or incident to a
providers service, the reduction described under this subitem applies to all
services furnished to a patient on the same day, regardless of whether the
services are provided in one therapy discipline or multiple disciplines, such
as physical therapy, occupational therapy, or speech-language pathology, and
regardless of the type of provider or supplier.
(4) For example (for illustrative purposes):
| Unadjusted Maximum Fee, Procedure 1 Unit
1 | Unadjusted Maximum Fee, Procedure 1 Unit 2 | Unadjusted
Maximum Fee, Procedure 2 | Total Adjusted Maximum Fee |
Calculation of Total Adjusted Maximum Fee |
| Work | $7 | $7 | $11 |
$25 | No reduction |
| PE | $10 | $10 | $8 |
$19 | $10 + (.50 x $10) + (.50 x $8) |
| Malpractice | $1 | $1 | $1 |
$3 | No reduction |
| Total | $18 | $18 | $20 |
$47 | $18 + ($7 + $1) + (.50 x $10) + ($11 + $1) + (.50 x $8) |
H. For diagnostic cardiovascular services
with an indicator of 6 in column S, the procedures must be ranked according to
the maximum fee for the technical component (TC) calculated according to the
formula in part
5221.4020, subpart 1b. Full
payment is made for the TC service with the highest payment. Payment is made at
75 percent for subsequent TC services furnished by the same provider, or by
multiple providers in the same group practice, to the same patient on the same
day. There is no reduction for the professional component (26). For example
(for illustrative purposes):
| Unadjusted Maximum Fee, Code 78452 |
Unadjusted Maximum Fee, Code 93306 | Total Adjusted Maximum Fee |
Calculation of Total Adjusted Maximum Fee |
| 26 | $77 | $65 | $142 | No
reduction |
| TC | $427 | $148 | $538 |
$427 + (.75 x $148) |
| Global | $504 | $213 |
$680 | $142 + $427 + (.75 x $148) |
I. For
diagnostic ophthalmology services with an indicator of 7 in column S, the
procedures must be ranked according to the maximum fee for the technical
component (TC) calculated according to the formula in part
5221.4020, subpart 1b. Full
payment is made for the TC service with the highest payment. Payment is made at
80 percent for subsequent TC services furnished by the same provider, or by
multiple providers in the same group practice, to the same patient on the same
day. There is no reduction for the professional component (26). For example
(for illustrative purposes):
| Code 92235 | Code 92250 | Total
Payment | Payment Calculation |
| 26 | $46 | $23 | $69 | No
reduction |
| TC | $92 | $53 | $134.40 |
$92 + (.80 x $53) |
| Global | $138 | $76 |
$203.40 | $69 + $92 + (.80 x $53) |
J. For
procedures with an indicator of 0 or 9, no payment rules for multiple or
endoscopy procedures apply.
Subp.
6.
Coding and payment for bilateral surgeries and
procedures.
Part
5221.4020, subpart 2a, item T, and
column T in the tables incorporated by reference in part
5221.4005, subpart 1, describe
codes subject to the bilateral procedures payment restrictions. Bilateral
surgeries are procedures performed on both sides of the body during the same
operative session or on the same day.
A. For procedures with an indicator of 0, 3,
or 9 in column T, no bilateral payment provisions apply.
For procedures with an indicator of 0, the 150 percent
bilateral adjustment in item B is inappropriate because of physiology or
anatomy or because the code description specifically states that it is a
unilateral procedure and there is an existing code for the bilateral procedure.
If the procedure is reported with modifier 50, or with modifiers RT and LT, the
maximum fee for both sides is the fee calculated according to part
5221.4020, subpart 1b, for a
single code. If the provider or payer reassigns a correct code for a bilateral
procedure the maximum fee is the amount calculated according to part
5221.4020, subpart 1b, for the
correct code and corresponding indicator.
Services with an indicator of 3 are generally radiology
procedures or other diagnostic tests that are not subject to bilateral payment
adjustments. If the procedure is reported with modifier 50 or is reported for
both sides on the same day by any other means, such as with RT and LT modifiers
or with a 2 in the units field, the maximum fee for each side is the amount
calculated according to the formula in part
5221.4020, subpart 1b, for each
side. If the procedure is reported as a bilateral procedure and with other
procedure codes on the same day, determine the maximum fee for the bilateral
procedure before applying any multiple procedure rules as specified in subpart
5, item C.
For procedures with an indicator of 9, the concept of bilateral
surgeries does not apply.
B. For procedures with an indicator of 1 in
column T, if the code is billed with modifier 50 or is reported twice on the
same day by any other means, such as with RT and LT modifiers or with a 2 in
the units field, the maximum fee is 150 percent of the amount calculated
according to the formula in part
5221.4020, subpart 1b, for a
single code. The bilateral adjustment is applied before any multiple procedure
rules as specified in subpart 5, item C.
C. For procedures with an indicator of 2, no
further bilateral adjustments apply because the RVUs are already based on the
procedure being performed as a bilateral procedure. If the procedure is
reported with modifier 50 or is reported twice on the same day by any other
means, such as with RT and LT modifiers or with a 2 in the units field, the
maximum fee for both sides is the amount calculated according to part
5221.4020, subpart 1b, for a
single code.
Subp. 7.
Coding and payment for assistant-at-surgery.
Part
5221.4020, subpart 2a, item U, and
column U in the tables incorporated by reference in part
5221.4005, subpart 1, describe
codes subject to the assistant-at-surgery payment restrictions. An
assistant-at-surgery must use the appropriate CPT or HCPCS modifier in
accordance with their provider type. Payment for a physician
assistant-at-surgery is not allowed when payment is made for cosurgeons or team
surgeons for the same procedures. For procedures with an indicator of 0 (where
medical necessity is established) or 2 in column U the maximum fee for an
assistant-at-surgery is as follows:
A.
For a physician who is an assistant-at-surgery, 16 percent of the global
surgery fee is paid. This is paid in addition to the global fee paid to the
surgeon.
B. If the assistant
surgery service is performed by a provider who is not a physician, but who has
advanced training to act as an assistant-at-surgery consistent with their scope
of practice, 13.6 percent of the global surgery fee is paid. This is paid in
addition to the global fee paid to the surgeon.
Subp. 8.
Coding and payment for
cosurgeons.
Part
5221.4020, subpart 2a, item V, and
column V in the tables incorporated by reference in part
5221.4005, subpart 1, describe
codes subject to the cosurgeon's payment adjustments. Under some circumstances,
the individual skills of two or more surgeons are required to perform surgery
on the same patient during the same operative session. This may be required
because of the complex nature of the procedures or the patient's condition. It
is cosurgery if two surgeons, each in a different specialty, are required to
perform a specific procedure, for example, heart transplant. Cosurgery also
refers to surgical procedures involving two surgeons performing the parts of
the procedure simultaneously, for example, bilateral knee replacement. In these
cases, the additional physicians are not acting as
assistants-at-surgery.
A. If
cosurgeons are required to do a procedure, each surgeon codes for the procedure
with CPT modifier 62 which indicate two surgeons.
B. For procedures with an indicator of 1,
where necessity of cosurgeons is established, or 2 in column V, the amount paid
for the procedure is 125 percent of the global fee, divided equally between the
two surgeons. If the cosurgeons have agreed to a different payment
distribution, payments will be made accordingly, if the agreed-upon
distribution is documented and explained on the bill for the procedure, and is
not prohibited by Minnesota Statutes, section
147.091,
subdivision 1, paragraph (p).
C.
For procedures with an indicator of 0 or 9 in column V, either cosurgeons are
not allowed or the concept of cosurgery does not apply and cosurgery fee
adjustments do not apply.
D. If
surgeons of different specialties are each performing a distinctly different
procedure with specific CPT codes, cosurgery fee adjustments do not apply even
if the procedures are performed through the same incision. If one of the
surgeons performs multiple procedures, the multiple procedure rules in subpart
5 apply to that surgeon's services.
Subp. 9.
Coding and payment for team
surgery.
Part
5221.4020, subpart 2a, item W, and
column W in the tables incorporated by reference in part
5221.4005, subpart 1, govern
application of the team surgery concept.
A. If a team of surgeons, that is, more than
two surgeons of different specialties, is required to perform a specific
procedure, each surgeon bills for the procedure with the CPT modifier 66 which
indicates a surgical team.
B. For
procedures with an indicator of 1, where necessity of a team is established, or
2 in column W, the amount paid for the procedure is limited by part
5221.0500, subpart 2, items B to
F, and Minnesota Statutes, section
176.136,
subdivision 1b.
C. For procedures
with an indicator of 0 or 9 in column W, either team surgery is not allowed or
the concept of team surgery does not apply.
Subp. 10.
Unbundling surgical
services.
Where several component services which have different CPT codes
may be described in one more comprehensive CPT code, only the single CPT code
most accurately and comprehensively describing the procedure performed or
service rendered may be reported. Intraoperative services, incidental
surgeries, or components of more major surgeries are not separately billable or
payable.
For example, an anterior arthrodesis of the lumbar spine using
the anterior interbody technique may be performed by two surgeons. One of the
surgeons may perform opening or the approach for the anterior arthrodesis while
a different surgeon performs the arthrodesis. In this instance, the surgeons
are acting as cosurgeons performing different components of a major surgery.
The opening or approach is not a separately billable or payable procedure. Both
surgeons must code this service using the anterior arthrodesis code and are
paid for the procedure as cosurgeons as specified in subpart 8.
Statutory Authority: MS s
14.38;
14.386;
14.388;
176.135;
176.1351;
176.136;
176.83
