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California Medical Bill Reviewer Re-Certification

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1 California Medical Bill Reviewer Re-Certification
Unit 2: Official Medical Fee Schedule Module 5: Surgery ©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care

2 Let’s begin by discussing general surgery guidelines...
Overview Lastly, you will learn about the different modifiers that are commonly found on surgical bills. Let’s begin by discussing general surgery guidelines... Then, in the second part of this module, you will learn how surgical assistants, co-surgeons, and microsurgeries are reimbursed differently. In the first part of this module, you will learn about general guidelines, and how different procedures are reimbursed. Hi! In this module, you will learn about surgical services, how they are reimbursed, and the circumstances that can affect reimbursement. Part I: Surgery Surgery Guidelines Procedures: Multiple Procedures Separate Procedures Microsurgery Procedures Spinal Fusion Exploration Part I: Surgery Surgery Guidelines

3 In the OMFS, the surgery section ranges from 10040-69979.
What is Surgery? Surgery is defined as the branch of medicine dealing with manual and operative procedures for correction of deformities and defects, repair of injuries, as well as diagnosis and cure of certain diseases. In the OMFS, the surgery section ranges from

4 This is apparent in the surgical section because:
Surgery Guidelines California has one of the most outdated fee schedules in the country. In some cases, this requires the use of older versions of the CPT and other references to clarify guidelines pertaining to old codes. This is apparent in the surgical section because: There are also rules and guidelines unique to California’s surgery section which you may not see in other states. New codes for current procedures have not been added. Old codes are still in place which have been deleted from the CPT.

5 Surgery Guidelines For example, many states simply allow an E & M service on the day of surgery if Modifier -57 is attached, which designates this service as a decision for surgery. However, California also further stipulates that prolonged detention or evaluation is required to determine the need for surgery. Let’s take a look…

6 Surgical Evaluation Prolonged Evaluation Required Prolonged Evaluation
Not Required If an injured worker is admitted for a head injury and has to be observed to determine if there is intracranial bleeding, prolonged evaluation is required. On the other hand, if an injured worker is admitted with an open fracture of the wrist prolonged evaluation or detention is not necessary, as it is obvious surgical intervention is needed.

7 Surgical Consultation
A valid consultation is also allowable the day of surgery, but it must qualify as a true consultation. “Hi...I have a patient here with an open wrist fracture...” A consultation is only allowable if... For example, if an orthopedic surgeon is called in by the ER physician to care for that open fracture of the wrist, he is not called to give an opinion--he is called to take over care of the patient. ...the physician is called in to give an opinion, not to take over care.

8 Multiple Procedures California is one of the few states with a multiple cascade rule for multiple surgical procedures that cascades beyond 50% reimbursement. A multiple cascade rule allows full reimbursement of the procedure with the highest value, and reduces the subsequent procedures by a percentage of the total fee schedule allowance. In CA, the multiple cascade is applied from the highest valued code to the lowest at 100%, 50%, and 25%, respectively. There are also a handful of minor arthroscopic procedures which only pay 10% of their fee schedule value when billed with other arthroscopic procedures on the same joint.

9 Multiple Procedures Multiple procedure values are built into the system and only need special attention when manual pricing is required. Multiple Procedure Example If five charges are billed and one is denied as an incidental procedure, the cascade is only applied to the remaining four procedures. As you learned, the highest paid procedure is reimbursed at 100% of fee schedule value, the second is paid at 50%, and the remaining two charges are paid at 25% of fee schedule value. It is important to remember the percentages are applied only to allowable charges and in the order of value, from highest to lowest.

10 These exceptions include the:
Multiple Procedures There are exceptions to multiple cascade rules. These exceptions include the: These codes are clearly marked in the fee schedule and are excluded from multiple cutback in the system. “each additional” code “add-on” code These codes are already discounted and are reimbursed at 100% of their fee schedule values.

11 Separate Procedures Like multiple procedures, there are reimbursement guidelines for those procedures unrelated to other services performed, known as Separate Procedures. The separate procedure designation in California is the same as CPT, but is widely misunderstood by providers and payors alike. Recall that separate procedures are independent of, and not immediately related to, other services performed, for which reimbursement is ALLOWED. Put another way, a separate procedure is only payable if it is billed alone, or with an unrelated service.

12 Microsurgery Microsurgery, which requires the use of magnification and extreme precision, is reimbursed differently in California than other states. California has not yet adopted the CPT microsurgery code and its instructions used in most states. Instead, microscope use is billed with CPT and is payable for intracranial and intradural procedures only.

13 Microsurgery This eliminates most spinal surgeries like diskectomies and fusions because these procedures are extradural, which means the surgeon carefully stays outside the dural sac surrounding the spinal cord. The system is programmed to deny CPT if billed with non-qualifying codes. No Reimbursement Use of loupes, or magnifying eyeglasses, does not qualify for microsurgery reimbursement.

14 Microsurgery So, what microsurgery procedures are payable?
CPT is payable for microscope use during intradural spinal surgery & intracranial surgery. The provider is reimbursed 25% of the primary procedure. CPT is payable for microscope use with nerve dissection or repair and is reimbursed 50% of the primary procedure. Modifier –20 is informational only and does not add to the reimbursement. Modifier –20 is used when a microsurgery requires a surgical microscope.

15 Exploration of Spinal Fusion
In contrast to Medicare and all other states, California allows CPT 22830: spinal fusion exploration to be billed with other spinal surgeries. Every other reference considers exploration of the operative field to be a basic service rendered as part of the primary service. In fact, physicians have been successfully sued for not exploring the operative area and identifying a cancer or other potential problem that could have been recognized and treated if only it had been recognized in time.

16 Exploration of Spinal Fusion
But the California OMFS states: “Exploration of spinal fusion, CPT 22830, is not incidental to other surgical spine procedures and is separately reimbursable.” The system is set up to allow this charge when billed with other spinal surgeries. Do not manually deny this code as included in other services. There must be a good neurosurgeon lobby in California!

17 Two issues are key to surgical assisting:
Surgical Assistants As you know, there is often an assistant present on a surgical case. Two issues are key to surgical assisting: Who assists the surgeon? Is the assistance necessary? Let’s take a look…

18 Licensed non-physician health care providers
Surgical Assistants California specifically limits surgical assisting to two different types of providers: Physicians Licensed non-physician health care providers Let’s take a look…

19 Surgical Assistants Physicians can used several different types of modifiers to bill for their services. Modifier –80 & -82 Modifier –81 Physicians who render minimal assistance—the assistant arrives late, leaves early, or both—use modifier –81 and are reimbursed 1.1 surgical units, regardless of the procedure performed. Physicians who render assistant care use modifiers –80 or –82 and are reimbursed 20% of the fee schedule allowance for each surgical procedure.

20 Non-physician assistants include:
Surgical Assistants The non-physician assistant group consists of three different types of providers who are licensed by the State. Non-physician assistants include: In contrast... Operating Room Technicians Certified Operating Room Technicians Office Assistants Registered Nurses RN First Assistants (RNFAs) Physician Assistants ...are not licensed by the State, and do not qualify for reimbursement if assisting in surgery.

21 Surgical Assistants Our system utilizes the eligibility criteria set out by Medicare to deny assistant charges for certain minor surgical procedures. This is accepted by the State and the provider community. California’s Official Medical Fee Schedule does not designate which procedures are allowable for assistant reimbursement.

22 Surgical Assistants Some surgical procedures do not require an assistant. The scrub nurse can provide sufficient assistance on minor services such as injections and manipulations, as well as certain small-field surgeries such as hands or ears. For example, common hand procedures can be adequately accomplished with a scrub nurse who retracts adjacent tissue, keeps the operative field dry, cuts suture, and performs other assistance as needed.

23 Co-Surgeons In some instances, the skills of two surgeons are required to perform a single surgical procedure. When the skills of two surgeons are required and they choose to work as equals rather than as a surgeon and assistant, they are designated co-surgeons. Let’s take a look…

24 Co-Surgeon Reimbursement
The reimbursement for two co-surgeons is calculated by the bill review system. The modifier –62 is attached to billed charges on each surgeon’s bill and the payment is increased by 25%, then split evenly between the co-surgeons unless they request a specific percentage split. Co-Surgeon Reimbursement (100% x Total Reimbursement) + (25% x Total Reimbursement) = 125% /2 = 62.5%

25 Co-Surgeon Reimbursement
Don’t forget that procedures performed by co-surgeons may be subject to both multiple cascade and co-surgeon reductions. Suppose two surgeons perform two procedures on the same patient. Procedure 1: Total Value = $ Procedure 2: Total Value = $500.00 $1500 x = $937.50 $500 x x 0.50 = $156.25 Co-Surgeon Reimbursement $ $ =

26 Modifiers As you know, modifiers attached to a billed charge are used to signify additional information for processing the charge. For instance, as you learned earlier, Modifier –80 tells us the bill is for the assistant and should be paid at 20% of the fee schedule allowance. As you just learned, some modifiers, liked Modifier –20, are informational and do not affect pricing at all. In addition to the modifiers that you have already learned about, there are several other commonly used modifiers on California surgery bills. Let’s take a look…

27 -22 Unusual procedural services:
Modifier –22 Modifier –22 indicates that a procedure was more difficult than normal. -22 Unusual procedural services: This modifier is used to indicate a procedure was more difficult due to unusual anatomy, excessive bleeding, extensive scarring, or any other problem that requires considerable additional time or skill.

28 Modifier –22 There is a normal range of difficulty for any procedure due to differences in personal anatomy. The provider is not paid less if the procedure is unusually easy, nor should he expect to be paid extra if the procedure is slightly more difficult than usual. Outside that normal range, though, a surgeon may request additional consideration for an unusually difficult case. Let’s take a look…

29 Modifier –22 Example 1 Example 2
Back surgery performed on a 500-pound man could be unusually difficult due to the positioning and depth of the incision required. A patient with bleeding problems could take much longer on the operating table than usual to make sure bleeding is controlled. The reimbursement for documented –22 usage is an additional 25% and is not necessarily applicable to the whole bill, but only to the difficult procedure specifically.

30 Modifier –25 Modifier –25 is used to indicate a separate E & M service provided on the same day as surgery. -25 Significant, separately identifiable E/M service on same day as surgery The key is documentation and pattern of visits. Let’s take a look…

31 Modifier –25 Example 1 Example 2 Example 3
If the procedure was scheduled in advance and only routine discussion of the procedural facts took place, the E/M visit is not a significant other service. If, at the time of a procedure, the next visit and procedure are scheduled and the questions are routine regarding the patient, his pain, or the procedure, the E/M visit is not justified whether or not a –25 is attached. Example 3 In contrast, if a provider discusses other conditions or problems with the patient, adjusts medications, or counsels them, the –25 is payable and the E/M visit can be allowed. For example, weekly pain injections with an accompanying E/M charge, billed with Modifier –25, should be questioned.

32 -47 Anesthesia by Surgeon: Regional anesthesia provided by a surgeon.
Modifier –47 You might remember from studying anesthesia that Modifier –47 is used to indicate that regional or general anesthesia was administered by a surgeon. -47 Anesthesia by Surgeon: Regional anesthesia provided by a surgeon. The surgeon is paid the base value of the anesthesia service without time units (the 1 required in the unit field is subtracted by the system). This is not applicable with local infiltration, digital block, topical application, or IV sedation.

33 -50 Bilateral Procedures:
Modifier –50 Modifier –50 is used to indicate that a bilateral procedure was performed. -50 Bilateral Procedures: Since the guidelines instruct to cascade bilateral procedures the same as multiple procedures, these cutbacks are all programmed into the system, and attaching the –50 is informational only. This prevents an automatic cutback for multiple procedures and an additional cutback for bilateral procedures.

34 Suppose three procedures are billed.
Modifier –50 Surgical procedures cascade from 100% to 50% to 25% whether they are unilateral or bilateral. Suppose three procedures are billed. Two procedures are bilateral and valued higher than the third service. Two procedures are bilateral and valued less than the third service. The first side would pay at 100%, the second side at 50%, and the final procedure at 25%, respectively. The third service would pay at 100%, and the bilateral procedures would pay 50% and 25%, respectively.

35 -51 Multiple Procedures:
Modifier –51 As you know, any surgical code, even injections, not designated as “add-on” or “each additional” is subject to reductions. Multiple procedures are indicated by Modifier –51. -51 Multiple Procedures: Multiple procedures are subject to the cascade rule, which reimburses the highest value procedure at 100%, and the subsequent procedures at 50% and 25%, respectively.

36 Modifier –51 There are a few things that you should remember when reviewing bills with multiple procedures. Multiple Procedures The primary procedure is not determined by billed charge, but by fee schedule value. The highest billed charge does not always correspond to the highest value. Body area change does not start the multiple cascade over. If the procedures are in the same operative session, they are subject to multiple cascade.

37 -59 Distinct Procedural Service:
Modifier –59 Sometimes a modifier is necessary to indicate a distinct procedure performed in conjunction with another procedure, normally part of the same primary service. In these instances, Modifier –59 is used. -59 Distinct Procedural Service: Used when a code normally included as part of a primary service is distinct enough to be considered a separate procedure.

38 Modifier –59 is NOT the magic pill to get a code paid.
There must be a justifiable reason why a procedure normally included in the primary service, within the same surgery, is not included, and is considered a separate procedure. Modifier –59 is NOT the magic pill to get a code paid. Merely placing this modifier on a billed code does not automatically qualify it for payment. Let’s take a look…

39 1. A diagnostic shoulder arthroscopy billed
Modifier –59 Example: Non-Reimbursable Example: Reimbursable 1. A diagnostic shoulder arthroscopy billed with a therapeutic arthroscopic procedure would normally not be reimbursable because they are both part of the same primary service. 1. However, if the diagnostic arthroscopy was performed in the opposite shoulder, -59 should be attached to the billed code and it should be paid, because the procedures are distinct and separate. 2. An injection code billed with a knee tendon repair would be included in the global surgical package, and therefore is not reimbursable. 2. But if the injection were in the other knee or a shoulder joint, it would be eligible for –59 and reimbursement.

40 Modifier –59 That’s right!
The processor must be aware that Modifier –59 is considered by the Federal Office of the Inspector General to be the most abused modifier in medical billing. Providers who misunderstand how to apply Modifier -59 place it on otherwise non-payable codes in the hope that it will pass through the system and be paid. What is the best way to confirm if Modifier –59 is being billed correctly? That’s right! Documentation that supports modifier –59 must be present in order to receive payment.

41 Summary Surgery: Guidelines, Evaluation, & Consultation
Reimbursement: Surgical Assistants & Co-Surgeons How multiple and separate procedures are reimbursed. Modifiers: How common modifiers affect reimbursement. How microsurgery and spinal fusion exploration procedures are reimbursed.

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