1. Provided by Coventry Health Care® ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Usual & Customary Medical Bill Reviewer Training Program Unit 3: Professional Services Module 4: Surgery

2. Usual & Customary Training - Surgery July 2011 Overview Part I: Surgery Surgery Guidelines Procedures: Multiple Procedures Separate Procedures Hi! In this module, you will learn about surgical services, how they are reimbursed, and the circumstances that can affect reimbursement. In the first part of this module, you will learn about general guidelines, and how different procedures are reimbursed. Then, in the second part of this module, you will learn how surgical assistants, co-surgeons, and microsurgeries are reimbursed differently. Part I: Surgery Surgery Guidelines Lastly, you will learn about the different modifiers that are commonly found on surgical bills. Lets begin by discussing general surgery guidelines...

3. Usual & Customary Training - Surgery July 2011 Surgical Consultation A valid consultation is allowable the day of surgery, but it must qualify as a true consultation. A consultation is only allowable if...... the physician is called in to give an opinion, not to take over care. 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. Hi...I have a patient here with an open wrist fracture...

4. Usual & Customary Training - Surgery July 2011 Multiple Procedures Multiple procedure values are built into the system and only need special attention when manual pricing is required. It is important to remember the percentages are applied only to allowable charges and in the order of value, from highest to lowest. 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 the UCR value, the second and subsequent services are paid at 50% of UCR value

5. Usual & Customary Training - Surgery July 2011 Multiple Procedures There are exceptions to multiple cascade rules. These exceptions include the: each additional code add-on code These codes are excluded from multiple cutback in the system.

6. Usual & Customary Training - Surgery July 2011 Multiple Endoscopy Procedures Endoscopy = a surgical examination of a closed body area with a scope. Examples: 29840 Wrist arthroscopy, diagnostic 31525 Diagnostic laryngoscopy Endoscopic family = all endoscopies performed in the same body area. Example: wrist, shoulder, abdomen, bladder

7. Usual & Customary Training - Surgery July 2011 Multiple Endoscopy Procedures Diagnostic endoscopies, also called base procedures, are not reimbursed with a surgical procedure in the same family. Examples: 29844 Wrist arthroscopy, surgical; synovectomy, partial 29840 Wrist arthroscopy, diagnostic (29840 is NOT PAID)

8. Usual & Customary Training - Surgery July 2011 Multiple Endoscopy Procedures If two surgical procedures in the same family are performed together, the value of the base (diagnostic) procedure is subtracted from the secondary procedure. Examples: 29844: Wrist arthroscopy, surgical; synovectomy, partial 29846: Wrist arthroscopy, surgical; triangular fibrocartilage repair 29840 (base) value would be subtracted from the secondary procedure 29844 Base

9. Usual & Customary Training - Surgery July 2011 Multiple Endoscopy Procedures If two endoscopies from different families are performed in the same session, they are not subject to the endoscopy rule, but would be reduced per the multiple rule. Overhead and pre- and post- operative services are only paid once. Example: 29822: Knee arthroscopy, surgical; synovectomy 29840: Wrist arthroscopy, diagnostic

10. Usual & Customary Training - Surgery July 2011 Separate Procedures Part I: Surgery Surgery Guidelines Procedures: Multiple Procedures Separate Procedures Now that you are familiar with multiple procedures, lets take a look at how separate procedures are reimbursed. Separate Procedures

11. Usual & Customary Training - Surgery July 2011 Separate Procedures Like multiple procedures, there are reimbursement guidelines for those procedures that are unrelated to other services performed, known as separate procedures. The separate procedure designation is widely misunderstood by providers and payors alike. 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. Usual & Customary Training - Surgery July 2011 Separate Procedures The separate procedure rule denies reimbursement for procedures that are related. The separate procedure rule typically applies to: Separate procedures that are performed in the same joint or body area as the primary service. Injections of supplemental medications into the same catheter. A manipulation or diagnostic service before the primary procedure.

13. Usual & Customary Training - Surgery July 2011 Surgical Reimbursements Many different people contribute to a single surgical procedure. Therefore, reimbursement depends on who performs or assists with the procedure. Lets start by discussing how surgical assistants are reimbursed for their services... Part II: Who Performs Surgery? Surgical Assistants Co-Surgeons Part II: Who Performs Surgery? Surgical Assistants

14. Usual & Customary Training - Surgery July 2011 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? Lets take a look…

15. Usual & Customary Training - Surgery July 2011 Surgical Assistants Physicians can use several different types of modifiers to bill for their services. Modifier -80, -81, & -82 Modifier – C7 Physicians who render assistant care use modifiers –80, -81, or -82 are reimbursed at the recommend payment according to the individual usual and customary states recommended payment. Non- Physicians who render assistance use modifier – C7 are reimbursed at the recommend payment according to the individual usual and customary states recommended payment.

16. Usual & Customary Training - Surgery July 2011 Surgical Assistants The non-physician assistant group consists of three different types of licensed providers. Non-physician assistants include: Registered Nurses Licensed Vocational Nurses Physician Assistants In contrast... Operating Room Technicians Certified Operating Room Technicians Office Assistants... are not licensed and do not qualify for reimbursement if assisting in surgery.

17. Usual & Customary Training - Surgery July 2011 Surgical Assistants Some surgical procedures do not require an assistant. If assistant charges are billed for these procedures, the system will automatically deny payment. 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 sutures, and performs other assistance as needed. Procedures for which an assistant WILL NOT be paid are designated with a 1 in the Assistant Surgeon column (Medicare Compliance Manual UCR section).

18. Usual & Customary Training - Surgery July 2011 Co-Surgeons Take a look… Sometimes, two surgeons work together to perform a single surgical procedure. Thanks Roger, for assisting with this shoulder arthroscopy. Lets proceed…

19. Usual & Customary Training - Surgery July 2011 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.

20. Usual & Customary Training - Surgery July 2011 Co-Surgeon Reimbursement The reimbursement for two co-surgeons is calculated by the bill review system. Dont forget that procedures performed by co-surgeons may be subject to both multiple cascade and co-surgeon reductions. The modifier –62 is attached to billed charges on each surgeons bill and each co- surgeon is paid at a percentage (instead of 100%) of the UCR reimbursement.

21. Usual & Customary Training - Surgery July 2011 Co-Surgeons Remember, check the report for more information! The operative report may help clarify the issue or a phone call to the provider may be required.

22. Usual & Customary Training - Surgery July 2011 Surgical Procedures Part III: Types of Surgeries Debridement Repairs Skin Grafts Weve discussed by whom procedures are performed. Now, lets talk about what procedures are allowed.

23. Usual & Customary Training - Surgery July 2011 Surgical Debridement (11040-11044) Remember; CPT codes 97597-97602 cannot be reported in conjunction with 11040-11044 The Procedure is billed alone, with no primary closure. A Gross contamination occurred with foreign matter. Significant devitalized tissue is involved. Normally, Debridement is not entitled for separate allowance. However, there are circumstances when it becomes necessary to perform the procedure. The exceptions apply when one of the following occurs…

24. Usual & Customary Training - Surgery July 2011 Surgical Repair When a patient presents with a wound that requires suturing, the closure repair type is determined by the location of the injury. The length of time required to perform the procedure is a factor as well. Repairs are categorized as Simple, Intermediate, and Complex. Within each repair type, there are several classifications, such as... Simple Repair (12001-12021): Involves superficial repair of the skin tissue, without deeper structures. Intermediate Repair (12031-12057): Involves simple repair, in addition to deep layer closures such as muscle and or facia. Complex Repair (13100-13160): Involves wounds requiring layered suturing, reconstructive surgery and or skin grafting. Lets take a look… Note: Complex repairs require a higher degree of finesse that are time consuming.

25. Usual & Customary Training - Surgery July 2011 Surgical Repair - Complex Repair of wounds associated with the performance of a primary procedure is included in the value of that procedure unless it is a complex wound. To recommend payment for a complex wound as a separate procedure, the multiple procedure guidelines should be applied. The following is an example of a complex wound repair billed with the multiple procedure rule applied: Primary Procedure: 25023 Elbow open wound w/complication Secondary 12002 Simple repair (4.6 cm) Tertiary 12034 Intermediate repair (12.50 cm) Additional 13122 Complex repair of the elbow (27.10 cm) Note: The complex repair includes cm of all repairs. As weve learned, simple and intermediate repairs are not reimbursed as separate procedures when billed with primary procedures.

26. Usual & Customary Training - Surgery July 2011 Skin Grafts Physicians determine the appropriate code for skin grafting, based on the size and location of the recipient area. Additionally, the type of graft must be considered. The types of grafts include the following: Full thickness or partial thickness Pedicle flap formation or immediate graft When a primary procedure is performed and requires a graft for closure, the physician should be entitled to payment for both. Also, repair of a donor site requiring skin graft or local flaps would be entitled to payment as a separate procedure. Payment for skin grafts is recommended for payment by allowing the first 100 sq. cm as the primary procedure. Each additional 100 sq. cm and the last fraction of 100 sq. cm are coded with each additional codes. Example: Primary procedure = 15100 Additional code = 15101

27. Usual & Customary Training - Surgery July 2011 Follow-up Care For Therapeutic Surgical Procedures Office visits are usually included in the follow-up care. Instances when care would be considered over and above the norm, therefore entitling a physician to additional allowances, are: Complications of the procedure. Exacerbations or recurrence. New diagnoses during the follow-up period. Keep in mind, a report is required to substantiate the necessity for the recommended payment.

28. Usual & Customary Training - Surgery July 2011 Modifiers Now that you understand how different types of surgical procedures are reimbursed, lets take a look at the different modifiers that providers may use on surgical bills. Lets start by discussing how modifiers are used to indicate a significantly difficult procedure on a bill... Part IV: Modifiers Modifier –22 Modifier –25 Modifier –51 Modifier –59

29. Usual & Customary Training - Surgery July 2011 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.

30. Usual & Customary Training - Surgery July 2011 Modifier –22 There is a normal range of difficulty for any procedure due to differences in personal anatomy. Outside that normal range, though, a surgeon may request additional consideration for an unusually difficult case. 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. Lets take a look…

31. Usual & Customary Training - Surgery July 2011 Modifier –22 The reimbursement for documented –22 usage is usually recommended at 25%, which has to be manually priced. The system is not automated to pay modifier -22. Example 1Example 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.

32. Usual & Customary Training - Surgery July 2011 Modifier –25 Modifier –25 is used to indicate a separate E & M service provided on the same day as a surgical service. The keys are documentation and pattern of visits. -25 Significant, separately identifiable E/M service on same day as surgery Lets take a look…

33. Usual & Customary Training - Surgery July 2011 Modifier –25 Example 1 Example 2 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. 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. Example 3 For example, weekly pain injections with an accompanying E/M charge, billed with Modifier –25, should be questioned.

34. Usual & Customary Training - Surgery July 2011 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%.

35. Usual & Customary Training - Surgery July 2011 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 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.

36. Usual & Customary Training - Surgery July 2011 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. -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. In these instances, Modifier –59 is used.

37. Usual & Customary Training - Surgery July 2011 Modifier –59 There must be a justifiable reason that 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. Lets take a look…

38. Usual & Customary Training - Surgery July 2011 Modifier –59 Example: Non-Reimbursable Example: Reimbursable 1. A diagnostic shoulder arthroscopy that is 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.

39. Usual & Customary Training - Surgery July 2011 Modifier –59 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. 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. What is the best way to confirm if Modifier –59 is billed correctly? Thats right! Documentation that supports modifier –59 must be present in order to receive payment.

40. Usual & Customary Training - Surgery July 2011 Summary Surgery: Guidelines, Evaluation, & Consultation How multiple and separate procedures are reimbursed. Reimbursement: Surgical Assistants & Co-Surgeons Modifiers: How common modifiers affect reimbursement. Great Job!