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.