Postoperative Periods
The difference between major and minor surgical procedures is reflected in the number of follow-up (postoperative) days after the surgery.
The Medicare Physician Fee Schedule Data Base (MPFSDB) will show the exact number of postoperative days associated with each procedure. The number of global days associated with a procedure can be found under the “GLOB DAYS” column in the MPFSDB. Postoperative periods are generally designated as follows:
Procedure Global Period
Major 90
Minor 0 or 10
Endoscopic 0
A surgery with 90 follow-up (postoperative) days is considered a major surgery.
A surgery with zero to 10 follow-up (postoperative) days is considered a minor surgery.
Some procedures in the surgical CPT range are strictly diagnostic (such as some endoscopies) and may not involve actual surgery. Most of these have “zero” follow-up days and include an allowance for the normal pre- and postoperative care associated with the procedure.
Note: See more information on billing minor surgeries and office visits under the 25 modifier.
Surgical Procedure Modifiers
LT Left Side - Used to identify procedures performed on the left side of the body. No effect on payment; however, failure to use when appropriate could result in delay or denial (or partial denial) of the claim.
RT Right Side - Used to identify procedures performed on the right side of the body. No effect on payment; however, failure to use when appropriate could result in delay or denial (or partial denial) of the claim.
22 Unusual procedural services - when the service(s) provided is greater than that usually required for the listed procedure. It may be identified by adding modifier -22 to the procedure number. A
report is also required.
50 Bilateral procedure - Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier -50 to the appropriate five digit code. The number of services is always reported as "1".
51 Multiple procedures - When multiple procedures, other than E/M services, are performed on the same day or at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) are identified by adding modifier -51.
PAYMENT RULES: The allowed is 100% of the fee schedule amount for the highest valued procedure, 50% of the fee schedule amount for the 2nd-5th procedures and "by report" for subsequent procedures.
EXCEPTIONS:
Multiple dermatology procedures: The allowed amount is 100% of the fee schedule amount for the highest valued procedure, 50% for each subsequent procedure.
52 Reduced services - Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service provided can be identified by its usual procedure code and the addition of the modifier -52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.
Note: For hospital out-patient reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of a patient prior to or after administration of anesthesia, see modifiers -73 and -74 (these modifiers are approved for ASC hospital out-patient use).
53 Discontinued procedure - Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier -53 to the code reported by the physician for the discontinued procedure.
Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers -73 and -74 (modifiers approved for ASC and hospital out-patient use).
54 Surgical care only - Use with surgical codes when one physician performs a surgical procedure and another provides preoperative and/or postoperative management.
55 Postoperative care only - Use with surgical codes when one physician performed the postoperative management and another physician performed the surgical procedure. The postoperative component may be identified by adding the modifier -55. Payment will be limited to the amount allotted for postoperative services only.
58 Staged or related procedure or service during the postoperative period - This modifier should be appended to surgical procedures when the physician needs to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure; e.g., a mastectomy follows a breast biopsy. Failure to use modifier when appropriate may result in denial of the subsequent surgery.
62 Two surgeons - When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable surgical procedure, each surgeon should report his/her distinct operative work by adding the modifier -62 to the single distinct procedure code. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedures) are performed during the same surgical session, separate codes may be reported without the modifier -62 added.
Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s), with modifier -80 or modifier.
66 Surgical team - Under some circumstance, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled specially trained personnel, various types complex equipment) are carried out under the "surgical team" concept. Such circumstances may be identified by each participating physician with the addition of the modifier -66 to the basic procedure number used for reporting services.
The modifier should be used by each participating surgeon to report his/her services. When team surgery is medically necessary, the carrier will determine the appropriate allowances(s) "by report."
76 Repeat procedure by same physician - The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier -76 to the repeated procedure or service.
77 Repeat procedure by another physician - The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier -77 to the repeated procedure or service.
78 Return to OR for related surgery during post-op period - Use on surgical codes only to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier -78 to the relate procedure.
Payment is limited to the amount allotted for intra-operative services only. Failure to use this modifier when appropriate may result in denial of the subsequent surgery.
79 Unrelated surgery during post-op period - Use on surgical codes only to indicate that the performance of a procedure during the postoperative period was unrelated to the original procedure. Failure to use this modifier when appropriate may result in denial of the subsequent surgery.
80 Assistant surgeon - Surgical assistant services may be identified by adding the modifier -80 to the usual procedure number(s). Medicare reimburses the assistant surgeon at 16% of the Medicare Physician Fee Schedule Data Base allowance for the surgical procedure.
Payment policy for Global Surgical services
Global Surgical Services
Services provided by another physician and/or health care professionals within the same group reporting the same Federal Tax Identification number will be included in the global surgical package reimbursement and not considered separately reimbursable.
Harvard Pilgrim reimburses surgical services at a single all-inclusive (global) contract rate. Payment includes:
• Pre-operative visits within 24 hours prior to a major surgery and on the same day a major or minor surgery is performed.
• Intra-operative services that are a usual and medically necessary part of the surgical procedure.
• Complications; all additional medical or surgical services rendered by the surgeon within the global period due to complications that do not require a re-operation or return trip to the operating room.
• Services for post-operative pain management rendered by the surgeon.
• Anesthesia services rendered by the surgeon.
• Miscellaneous services, such as:
- Dressing changes
- Other routine post-operative services
- Removal of or change of, tracheostomy tubes
- Removal of sutures, lines, wires and splints, etc.
- Removal of urinary catheters, routine IV lines
• All post-operative visits, both inpatient and outpatient, within the global period related to the surgical procedure.
• Harvard Pilgrim follows the global period indicator as designated by CMS of 0, 10, 90 or YYY for each Procedure code.
Surgical Services Reimbursed Outside of the Global Rate When Billed With Appropriate Modifier
• Services rendered for post-operative complications requiring a return trip to the operating room.
• Services of another physician, unless the physician is part of the same specialty group practice.
• If one physician performs the surgery but a different physician renders post-operative care, each service is reimbursed separately.
• For surgical procedures with zero days assigned as a global period, post-operative visits are reimbursed
• Visits unrelated to the diagnosis (see below for same day significant E&M with global day service)
- Treatment for an underlying condition
- An added course of treatment not related to the surgery
• Diagnostic tests and procedures, including radiological procedures
Insurance payment for E & M service on Global day and multiple procedures
Significant, Separately Identifiable E&M with Global Day Service—Same Day
Policy will apply to all professional services performed in an office place of service, when significant, separately identifiable E/M service (appended with 25 modifier) and any service that has a global period indicator as designated by CMS of 0, 10, 90 or YYY is performed on the same day, E&M service will be reimbursed at 50% of the contracted allowable. When the E&M value is greater than the procedure, the reduction will be applied to the global procedure code.
Bundled Services
Harvard Pilgrim reimburses only the most intensive CPT code when:
• A procedure is considered to be normally included as part of a more comprehensive code.
• A single, more comprehensive CPT code more accurately describes a group of procedures.
• If a procedure that is generally carried out as an integral part of a larger surgical procedure is performed alone and independent of other surgical services, it is reimbursable.
Multiple Procedures
• When multiple procedures are performed at the same session, the primary procedure is reimbursed at 100% of the allowable rate and all subsequent reimbursable procedures are paid at 50% of the allowable rate.
• Harvard Pilgrim determines the primary procedure based on the highest allowable rate, not the charge.
Bilateral Surgeries
• Bilateral surgeries are reimbursed at 150% of the allowable rate.
• Bilateral assistant surgeons are reimbursed at 16% of the allowable 150% amount.
Professional, Multiple and Bilateral Surgery Services Performed During the Same Operative Session
When a bilateral procedure code and surgical procedure(s) are performed at the same session and eligible for multiple procedure reduction, claim will be subject to multiple procedure reduction and bilateral procedure payment adjustment in accordance with Harvard Pilgrim payment policy.
If the bilateral procedure is the secondary procedure, multiple procedure reduction and bilateral procedure payment adjustment will be applied.
Add-on Codes
• Add-on codes are reimbursed at 100% of the allowable rate and are not subject to the multiple procedure reduction.
• Add-on codes are only those codes designated by CPT and identified by a specific descriptor that includes the phrase “each additional” or “list separately in addition to the primary procedure.”
• Add-on codes are reimbursable only when billed with their primary procedure.
Cosmetic Surgery
Cosmetic surgery is reimbursable with prior authorization of any cosmetic surgery exceptions, including, but not limited to:
• Repair of an accidental injury (e.g., repair of the face following a serious automobile accident).
• Improved function of a malformed body part.
• Treatment of severe burns.
• For additional information, refer to the Cosmetic, Reconstructive and Restorative Procedures Payment Policy.
E&M services provided within global period
Based on the CMS global surgical period:
• FCHP does not separately reimburse for any E&M service when reported with major surgical procedures (90-day global surgical period)
• FCHP does not separately reimburse for any E&M service when reported with minor procedures with a 10-day post-op period.
• FCHP does separately reimburse for new patient E&M services and E&M services described in Proceure as applying to new or established patients when reported with minor procedures with a 0-day post-op period.
• FCHP does consider reimbursement for services rendered during the global period if the appropriate modifier -24 is appended to the E&M procedure code and medical notes are included.
Services rendered in the office after-hours or on weekends or holidays
• FCHP reimburses Proceure Code 99050 for services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday), in addition to basic service.
• FCHP reimburses Proceure Code 99051 for services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.
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