3.0 POLICY
3.1
Multiple
Surgery And Discounting Reimbursement
3.1.1 The following rules are to
be followed whenever there is a terminated procedure or more than
one surgical procedure performed during the same operative or outpatient
session. This applies to those facilities that are exempt from the
hospital Outpatient Prospective Payment System (OPPS) and for claims
submitted by individual professional providers for services rendered
on or after May 1, 2009 (implementation of OPPS):
3.1.1.1
Discounting
for Multiple Procedures
3.1.1.1.1 When more
than one surgical procedure code subject to discounting (see
Chapter 13, Section 3) is performed during
a single operative or outpatient session, TRICARE will reimburse
the full payment and the beneficiary will pay the cost-share/copayment
for the procedure having the highest payment rate. Beginning January
1, 2015, Medicare introduced comprehensive Ambulatory Payment Classifications
(APCs) under the OPPS. Surgical procedures considered part of comprehensive
APCs (Status Indicator (SI) of
J1) provided in facilities
exempt from OPPS are also subject to discounting for multiple procedures
under this paragraph, in addition to those procedures listed in
Chapter 13, Section 3, paragraph 3.1.5.2.
3.1.1.1.2 Fifty percent
(50%) of the usual payment amount and beneficiary copayment/cost-share
amount will be paid for all other procedures subject to discounting
(see
Chapter 13, Section 3) performed during the
same operative or outpatient session to reflect the savings associated
with having to prepare the patient only once and the incremental
costs associated with anesthesia, operating and recovery room use,
and other services required for the second and subsequent procedures.
• The
reduced payment would apply only to the surgical procedure with
the lower payment rate.
• The reduced payment
for multiple procedures would apply to both the beneficiary copayment/cost-share
and the TRICARE payment.
Note: Certain codes are considered an add-on or modifier
51 exempt procedure for non-OPPS professional and facility claims,
which should not apply a reduction as a secondary procedure. These codes
should not be subject to OPPS discounting reduction defined in
Chapter 13, Section 3. The source for these
codes is the American Medical Association (AMA) Current Procedural
Terminology (CPT) guide.
3.1.1.2 Discounting for Bilateral
Procedures
Note: Bilateral codes can be surgical and
non-surgical.
3.1.1.2.1 Following
are the different categories/classifications of bilateral procedures:
• Conditional
bilateral (i.e., procedure is considered bilateral if the modifier
50 is present).
• Inherent
bilateral (i.e., procedure in and of itself is bilateral).
• Independent bilateral
(i.e., procedure is considered bilateral if the modifier 50 is present,
but full payment should be made for each procedure (e.g., certain radiological
procedures).
3.1.1.2.2 Terminated
bilateral procedures or terminated procedures with units greater
than one should not occur. Line items with terminated bilateral
procedures or terminated procedures with units greater than one
are denied.
3.1.1.2.3 Inherent
bilateral procedures will be treated as a non-bilateral procedure
since the bilateralism of the procedure is encompassed in the code.
3.1.1.3
Modifiers
for Discounting Terminated Surgical Procedures
3.1.1.3.1 Industry
standard modifiers may be billed on outpatient hospital or individual professional
claims to further define the procedure code or indicate that certain
reimbursement situations may apply to the billing. Recognition and
utilization of modifiers are essential for ensuring accurate processing
and payment of these claim types.
3.1.1.3.2 Industry
standard modifiers are used to identify surgical procedures which
have been terminated prior to and after the delivery of anesthesia.
• Modifiers
52 and 73 are used to identify a surgical procedure that is terminated prior
to the delivery of anesthesia and is reimbursed at 50% of the allowable;
i.e., the Ambulatory Surgery Center (ASC) tier rate, the APC allowable
amount for OPPS claims, or the CHAMPUS Maximum Allowable Charge
(CMAC) for individual professional providers.
• Modifiers 53 and 74
are used for terminated surgical procedures after delivery of anesthesia
which are reimbursed at 100% of the appropriated allowable amounts referenced
above.
3.1.2 Exceptions
to the above policy prior to implementation of the hospital OPPS,
are:
3.1.2.1 If the multiple surgical procedures involve
the fingers or toes, benefits for the third and subsequent procedures
are to be limited to 25% to the prevailing charge.
3.1.2.2 Incidental
procedures. No reimbursement is to be made for an incidental procedure.
3.1.3 Separate
payment is not made for incidental procedures. The payment for those procedures
are packaged within the primary procedure with which they are normally
associated.
3.1.4 Data which is distorted because of these multiple
surgery procedures (e.g., where the sum of the charges is applied
to the single major procedure) must not be entered into the data
base used to develop allowable charge profiles.
3.1.5
The Inpatient
Only Procedure List3.1.5.1 The OPPS inpatient only list shall apply to
OPPS, non-OPPS, and, through September 30, 2015, individual professional
providers.
3.1.5.3 Beginning April 1, 2017, the
inpatient only list shall no longer apply to the services rendered
by hospital outpatient departments in states with Centers for Medicare
and Medicaid Services (CMS) waivers (e.g., Maryland).
3.2 Multiple
Primary Surgeons
When more than one surgeon
acts as a primary surgeon for multiple procedures during the same
operative session, the services of each may be covered, subject
to the following considerations:
• For co-surgeons (modifier
62), TRICARE pays 125% of the global fee and divides the payment
equally between the two surgeons. This means that each surgeon receives
62.5% of the TRICARE allowable charge for each procedure. No payment
may be made for an assistant surgeon in such cases.
• For team surgery (modifier
66), payment needs to be determined on a case-by-case basis. Team
surgery cases may be seen with organ transplants, separation of
siamese twins, severe trauma cases, and cases of a similar nature.
• Payment may not be
made to any of the primary surgeons for assisting any of the other primary
surgeons.
3.4 Pre-Operative
Care
Pre-operative care rendered in a hospital
when the admission is expressly for the surgery is normally included
in the global surgery charge. The admitting history and physical
is included in the global package. This also applies to routine
examinations in the surgeon’s office where such examination is performed
to assess the beneficiary’s suitability for the subsequent surgery.
3.5 Post-Operative
Care
All services provided by the surgeon
for post-operative complications (e.g., replacing stitches, servicing
infected wounds) are included in the global package if they do not
require additional trips to the operating room. All visits with
the primary surgeon during the 90-day period following major surgery
are included in the global package.
Note: This rule does not apply if the visit is for a
problem unrelated to the diagnosis for which the surgery was performed
or is for an added course of treatment other than the normal recovery
from surgery. For example, if after surgery for cancer, the physician
who performed the surgery subsequently administers chemotherapy
services, these services are not part of the global surgery package.
3.6 Re-Operations
For Complications
All medically necessary
return trips to the operating room, for any reason and without regard
to fault, are covered.
3.7
Global
Surgery For Major Surgical Procedures
Physicians
who perform the entire global package which includes the surgery
and the pre- and post-operative care should bill for their services
with the appropriate CPT code only. Do not bill separately for visits
or other services included in this global package. The global period
for a major surgery includes the day of surgery. The pre-operative
period is the first day immediately before the day of surgery. The
post-operative period is the 90 days immediately following the day
of surgery. If the patient is returned to surgery for complications
on another day, the post-operative period is 90 days immediately
after the last operation.
3.8
Second Opinion
3.8.1 Claims
for patient-initiated, second-physician opinions pertaining to the
medical need for surgery or other major nonsurgical diagnostic and
therapeutic procedures (e.g., invasive diagnostic techniques such
as cardiac catheterization and gastroscopy) may be paid. Payment
may be made for the history and examination of the patient as well
as any other covered diagnostic services required in order for the
physician to properly evaluate the patient’s condition and render
a professional opinion on the medical need for surgery or other
major nonsurgical diagnostic and therapeutic procedure.
3.8.2 In the
event that the recommendations of the first and second physician
differ regarding the medical need for such surgery or other major
nonsurgical diagnostic and therapeutic procedure, a claim for a
patient-initiated opinion from a third physician is also reimbursable.
Such claims are payable even though the beneficiary has the surgery
performed against the recommendation of the second (or third) physician.
3.9
In-Office Surgery
Charges for a surgical suite in an individual
professional provider’s office, including charges for services rendered
by other than the individual professional provider performing the
surgery and items directly related to the use of the surgical suite,
may not be cost-shared unless the suite is an approved ASC.
3.10 On May
1, 2009 (implementation of OPPS), surgical procedures will be discounted
in accordance with the provisions outlined in
Chapter 13, Section 3, paragraphs 3.1.5.2 and
3.1.5.3. Multiple discounting will not be
applied to the following CPT procedure codes for venipucture, fetal monitoring
and collection of blood specimens; 36400-36416, 36591, 36592, 59020,
59025, 59050, and 59051.