Current through Register Vol. 56, No. 18, September 16, 2024
(a) Anesthesia: The following HCPCS procedure codes do not require the AA modifier when the professional services are rendered by an anesthesiologist:
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(b) Incidental Surgery: Certain surgical procedures when performed incidental to other surgical procedures by the operating surgeon or assistant surgeon are covered in the reimbursement allowance for the primary procedure. Such incidental procedures are as follows:
1. Breast biopsy (HCPCS 19100, 19101, 76095)-with other breast surgery (HCPCS 19110-19240);
2. Tracheostomy (HCPCS 31600-31610) with procedures such as the following:
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3. Exploratory Thoracotomy (HCPCS 32095-32160) with other major thoracic procedures;
4. Splenectomy (HCPCS 38100-38101, 38115) with Gastrectomy procedures (HCPCS 43620-43638);
5. Appendectomy (HCPCS 44950) performed on a non-diseased appendix with any major abdominal surgery;
6. Gastrostomy (HCPCS 43830) following or preceding a subtotal or hemigastrectomy; gastrorrhaphy (HCPCS 43840); vagotomy and pyloroplasty (HCPCS 43640); gastroduodenostomy (HCPCS 43810; or other gastric procedures (HCPCS 43500-43885) or esophageal resections (HCPCS 43400-43499) or pancreatic surgery (48100-48180);
7. Enterolysis (freeing of intestinal adhesions- HCPCS 44005) and Lysis of adhesions (salpingolysis, ovariolysis) with other major abdominal surgery or uterine, salpingeal, ovarian surgery or C-Section;
8. Ileostomy (HCPCS 44310), colostomy or cecostomy (HCPCS 44320) procedures performed in conjunction with procedures such as the following small intestine, colon or rectal procedures (HCPCS 44140-44155, 45110-45135);
9. Exploratory Laparotomy (HCPCS 49000) with other intra-abdominal surgical procedures;
10. Retroperitoneal Exploration (HCPCS 49010) with other major procedures in the pelvic or abdominal area;
11. Omentectomy (HCPCS 49255) with any total or partial gastrectomy for malignancy or other gastric, small bowel, colon, pancreatic surgery or combined abdominal-perineal resection;
12. Exploratory Cystotomy (HCPCS 51020-51045) with other major urinary bladder procedures requiring an incision into the bladder;
13. Biopsy of ovary (HCPCS 58900) and drainage of ovarian cyst (HCPCS 58800-58822) with any intra-abdominal surgery including ovarian, uterine or salpingeal surgery;
14. Exploratory Craniotomy (HCPCS 61304, 61305) with any other brain surgery; (HCPCS 61312-61576; 61680-61711; 62000-62258);
15. Biopsy of Testis, needle (HCPCS 54505)-with any inguinal hernia repairs, orchiectomy, exploration of undescended testis, reduction or fixation of testis, hydrocele and scrotal surgery;
16. Eye Surgery for Removal of Cataracts-(HCPCS 66920, 66930, 66940) with any other optical procedure.
(c) Second surgical opinion: A second surgical opinion is not required for the following procedures:
1. All surgical procedures related to cholecystectomy;
2. Hernia repairs for recipients under 19 years of age;
3. Primary adenoidectomy for children under 12 years of age; and
4. Spinal fusion and laminectomy for scoliosis for recipients under 19 years of age.
5. It should be emphasized that the requirement for Second Surgical Opinion is waived when the operating physician determines that the need for surgery is urgent or emergent. For Second Opinion purposes, "urgent or emergent" means that a delay in surgery to comply with the protocol of the Second Surgical Opinion Program would result in a significant threat to the patient's health or life.
6. To facilitate reimbursement in instances where the surgery meets the "urgent/emergent" definition, the physician or independent clinic must attach to the claim form, a statement from the operating physician attesting to the urgent/emergent nature of the illness or situation. (See previous Newsletters, P-329 (3/22/82) and P-339 (10/4/82).
7. No Medicaid Second Surgical Opinion Referral Form (FD-263) (9/91) will be required for claims submitted by an anesthesiologist or an assistant surgeon.
(d) Second surgical opinion: The following HCPCS codes do require a Second Surgical Opinion:
1. Hysterectomy (Elective Procedures):
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4. Hernia Repair (Unilateral or Bilateral including umbilical hernia-for recipients 19 years of age or older):
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(e) Multiple surgical pricing: The following HCPCS procedure codes are excluded from multiple surgical pricing and as such and shall be reimbursed like the primary procedure at 100 percent of the Medicaid Maximum Fee Allowance even when the procedure is done on the same patient, by the same surgeon, at the same operative session.
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(f) Surgery and office visit (New and Established Patient) Conflicts: The following procedure codes are excluded from the policy indicating that office visit codes are not reimbursed in addition to procedure codes for other conditions. Thus, the following Office Visit (New and Established Patient) procedure codes, listed below, may be billed with the procedure codes listed identified with the titles, Surgery Values and Excluded Codes. (If the surgical procedure code reimburses less than an Office Visit, reimbursement will be the higher of the office visit rate or the surgical procedure code rate, not both.)
1. The policy is applicable to these surgical procedure codes:
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2. The policy is also applicable to office visit (new and established patient) procedure codes:
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3. The following procedure codes are excluded from this policy:
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(g) Rehabilitative services: When requesting reimbursement for the following HCPCS procedure codes, a separate service line shall be completed for each day that the service is provided. Providers shall not "span bill" for services.
92507
97799
H5300
(h) Mental health services: When requesting reimbursement for the following HCPCS procedure code, a separate service line shall be completed for each day that the service is provided. Providers shall not "span bill" for services.
90870
