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.