Current through Register Vol. 24-18, September 15, 2024
(1) The agency's global surgical
reimbursement for all covered surgeries includes all of the following:
(a) The operation itself;
(b) Postoperative dressing changes,
including:
(i) Local incision care and removal
of operative packs;
(ii) Removal of
cutaneous sutures, staples, lines, wire, tubes, drains, and splints;
(iii) Insertion, irrigation, and removal of
urinary catheters, routine peripheral intravenous lines, nasogastric and rectal
tubes; or
(iv) Change and removal
of tracheostomy tubes.
(c) All additional medical or surgical
services required because of complications that do not require additional
operating room procedures.
(2) The agency's global surgical
reimbursement for major surgeries, includes all of the following:
(a) Preoperative visits, in or out of the
hospital, beginning on the day before surgery; and
(b) Services by the primary surgeon, in or
out of the hospital, during a standard ninety-day postoperative
period.
(3) The agency's
global surgical reimbursement for minor surgeries includes all of the
following:
(a) Preoperative visits beginning
on the day of surgery; and
(b)
Follow-up care for zero or ten days, depending on the procedure.
(4) When a second physician
provides follow-up services for minor procedures performed in hospital
emergency departments, the agency does not include these services in the global
surgical reimbursement. The physician may bill these services
separately.
(5) The agency's global
surgical reimbursement for multiple surgical procedures is as follows:
(a) Payment for multiple surgeries performed
on the same client on the same day equals one hundred percent of the agency's
allowed fee for the highest value procedure. Then,
(b) For additional surgical procedures,
payment equals fifty percent of the agency's allowed fee for each
procedure.
(6) The agency
allows separate reimbursement for any of the following:
(a) The initial evaluation or
consultation;
(b) Preoperative
visits more than one day before the surgery;
(c) Postoperative visits for problems
unrelated to the surgery; and
(d)
Postoperative visits for services that are not included in the normal course of
treatment for the surgery.
(7) The agency's reimbursement for endoscopy
is as follows:
(a) The global surgical
reimbursement fee includes follow-up care for zero or ten days, depending on
the procedure.
(b) Multiple surgery
rules apply when a provider bills multiple endoscopies from different endoscopy
groups. See subsection (4) of this section.
(c) When a physician performs more than one
endoscopy procedure from the same group on the same day, the agency pays the
full amount of the procedure with the highest maximum allowable fee.
(d) The agency pays the procedure with the
second highest maximum allowable fee at the maximum allowable fee minus the
base diagnostic endoscopy procedure's maximum allowed amount.
(e) The agency does not pay when payment for
other codes within an endoscopy group is less than the base code.
(8) The agency restricts
reimbursement for surgery assists to selected procedures as follows:
(a) The agency applies multiple surgery
reimbursement rules for surgery assists . See subsection (4) of this
section.
(b) Surgery assists are
reimbursed at twenty percent of the maximum allowable fee for the surgical
procedure.
(c) A surgical assist
fee for a registered nurse first assistant (RNFA) is reimbursed if the nurse
has been assigned a provider number.
(d) A provider must use a modifier on the
claim with the procedure code to identify surgery assist.
(9) The agency bases payment splits between
preoperative, intraoperative, and postoperative services on medicare
determinations for given surgical procedures or range of procedures. The agency
pays any procedure that does not have an established medicare payment split
according to a split of ten percent - eighty percent - ten percent
respectively.
(10) For preoperative
and postoperative critical care services provided during a global period refer
to WAC 182-531-0450.
11-14-075, recodified as §182-531-1700, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.08.090. 10-19-057, § 388-531-1700,
filed 9/14/10, effective 10/15/10. Statutory Authority:
RCW
74.08.090,
74.09.520. 01-01-012, §
388-531-1700, filed 12/6/00, effective
1/6/01.
