1

Medifest 2013

Global Surgery:

Dissecting the Guidelines March 13, 2013

Proprietary and Confidential

1

Presented By

First Coast Service Options, Inc.

Provider Outreach & Education

Cara Page

Provider Relations Representative

2

Disclaimer

This presentation was prepared by First Coast for informational

and educational purposes only; it is not legal advice or a legal

document, and should not be relied upon. The presentation

serves as a general summary of complex rules and regulations

which may change; the presentation is not guaranteed to be

complete, correct, timely or current, and First Coast bears no

responsibility or liability for the results or consequences of the

use or reliance on the information in this presentation. No portion

or element of this presentation may be copied, in whole or in

part, for profit-making purposes without the express written

consent of First Coast.

2

3

Acronym List

ASC – Ambulatory Surgical Center

CMS – Centers for Medicare & Medicaid Services

CPT – Current Procedural Terminology

E/M – Evaluation and Management

HCPCS – Healthcare Common Procedure Coding System

IOM – Internet Only Manual

MPFSDB – Medicare Physician Fee Schedule Database

NPP – Nonphysician Practitioner

RNFA – Registered Nurse First Assistant

UTI-Urinary Tract Infection

WBT – Web-based training

3

Agenda Items

Components of global surgical package

Modifiers

Split care

Surgical assistant/assistant at surgery

Types of surgery/reimbursement methodology

Medicare Physician Fee Schedule Database (MPFSDB)

Additional resources

Summary of today’s topics

Question and answer session

4

Learning Objectives

After this session you will be able to • Explain the components of the global surgical package

• Apply modifiers pertaining to global surgery

• Identify correct billing and reimbursement methods

• Review information within the Medicare Physician Fee Schedule Database

• Locate resources to assist in understanding global surgery rules

5

4

Global Surgery

6

National policy established in 1992

Ensures consistent payment for services across all jurisdictions

Includes all necessary services considered part of a surgical

procedure before, during, and after surgery

Services may be furnished in any setting

Hospital (inpatient /outpatient)

Ambulatory Surgical Center (ASC)

Physician office

Intensive care/critical care unit

7

Global Surgery Concept

5

Pre-operative visits

Intra-operative services

Complications following surgery (infection, fever, UTI)

Post-operative visits

Post-surgical pain management by surgeon

Miscellaneous services (dressing changes, suture removal,

staples, tubes)

8

Services Included

Initial consultation

Visits unrelated to surgery

Added courses of treatment

Complications during post-operative period which require return

trip to operating room

Diagnostic tests

Distinct surgical procedures

Immunotherapy management

More extensive procedures

Unrelated critical care services for seriously injured or burned

patients

9

Services Not Included

6

Postoperative Periods

Minor & Endoscopic

Procedures

No pre-operative days

0 or 10-day

post-operative period

Major Surgical

Procedures

1-day pre-operative

(day before surgery)

90-day

post-operative period

10

Medicare Physician Fee Schedule

Data Base

11

7

Select Medicare Physician and Nonphysician Practitioner Fee

Schedule (MPFS)

Enter date of service

Determine locality via link at top (“click here”)

Enter procedure code

Submit

Select “more” in Modifier field

Global Surgery field gives number of post-op days

http://medicare.fcso.com/Fee_lookup/fee_schedule.asp

12

Payment Policy Indicators

Billing Requirements

13

8

Physicians who furnish entire global

surgical package Bill appropriate current procedural terminology (CPT) code for

surgery “only”

No separate billing for visits related to surgery

Physicians in group practice If different physicians participate in the care of the patient, the group

bills for the entire global package if the physicians reassign benefits

to the group

Physician who performs surgery is reported as the performing

physician

14

Billing Guidelines

Surgery Modifiers

15

9

Surgical Modifiers

58 – Staged or related procedure or service by the same

physician during the post-operative period

Planned or anticipated

More extensive than the original procedure

Therapy following a surgical procedure

78 – Unplanned return to operating room for related procedure

during post-operative period

79 – Unrelated procedure or service by same physician during

post-operative period

16

Surgery Modifier

Exercises

17

10

Modifier Exercise

Patient undergoes a radical mastectomy (90 day post-op). The

patient will have a permanent prosthesis after the surgical wound

has healed. The surgeon performs the insertion of the

permanent prosthesis during the post-operative period.

What modifier is used to report the procedure performed in the

post operative period?

18

Modifier Exercise

Patient undergoes a cholecystectomy on Wednesday. On Friday

(2 days following the surgery), the patient develops increasing

abdominal pain and is returned to the operating room. The

surgeon performs a diagnostic laparoscopy where scarring and

adhesions are found. The surgeon performs a lysis of the

adhesions.

What modifier is used to report the procedure performed in the

post operative period?

19

11

Modifier Exercise

Patient has a repair of initial femoral hernia (49550)

90 days post-op procedure

Five weeks later an appendectomy (44950) is done

What modifier is used to report the procedure performed in the

post operative period?

20

Evaluation and Management

Modifiers

21

12

E/M Modifiers

24 - Unrelated service by same physician during post-operative

period

25 - Significant, separately identifiable E/M service by same

physician on same day of procedure

57 - Service that resulted in initial decision to perform surgery

22

E/M Modifier

Exercises

23

13

Modifier Exercise

Dr. Adams, an orthopedist, performs knee surgery on a patient,

a 90-day global period. On day 55 of the post-op period, the

patient comes in the office complaining of numbness and tingling

in his right hand. Dr. Adams performs an exam and diagnoses

the patient.

What modifier, if any is required with the E/M service during the

post-op period of the knee surgery?

24

Modifier Exercise

An established patient visited her physician’s office for a chief

complaint of back pain. The physician examines and evaluates

the patient and determines that an infected cyst is causing the

pain. The physician decides to incise the cyst during the office

visit.

What modifier, if any, is needed to code the E/M service?

25

14

Modifier Exercise

A patient comes into the emergency department with severe

abdominal pain. A general surgeon is consulted and performs an

E/M service, the general surgeon admits the patient and plans to

perform a major surgery the following day.

What modifier, if any, should be appended to the appropriate

E/M code?

26

Split Care

27

15

How to Bill Transfer of Care

Modifier 56: pre-operative management only

Modifier 54: surgical care only

Modifier 55: post-operative management only

28

29

Split Care Billing

Scenarios

16

Split Care Scenarios

Dr. Kildare performed a surgery (66984) on January 1 and saw the

patient for follow up care through January 10. Dr. Kildare then

transferred the care over to the patient’s optometrist , Dr. Casey,

who relinquished care on April 1.

OR

Dr. Kildare performed surgery (66984) on January 1. He then

transfers the patient over to their optometrist ,Dr. Casey, on

January 2.

30

Split Care Breakdown

Surgeon’s Care

(Dr. Kildare)

Co-managing Physician Care

(Dr. Casey)

Date CPT Code

January 1 66984-54

January 2 – 10 66984-55

Date CPT Code

January 11– April 1 66984-55

Date of service = 1/1/13

Date of service = 1/1/13

Claim form block 19 =

Assumed post-op care on 1/2/13,

relinquished on 1/10/13.

Claim form block 19=

Assumed post-op care on 1/11/13,

relinquished on 4/1/13.

31

17

Common Split Care Billing Errors

Incorrect date of service on the claim

Billing 55 modifier using a different surgical procedure than billed

initially by the surgeon

Block 19 on CMS 1500 claim form is left blank-no assumed or

relinquished dates indicated

Appropriate modifiers not used by the surgeon or physician

assuming the post operative care

Surgeon bills his/her claim without appropriate modifier, causing

claim to deny for physician billing post op care. (Claim billed in

this manner appears as though the surgeon did surgery and post

op care)

32

Surgical Assistant

vs.

Assistant at Surgery

33

18

Modifier 80 vs. AS

Modifier 80

Surgical Assistant

Physician

16% of fee schedule allowance

Modifier AS

Assistant-at-Surgery

Physician Assistant, Nurse Practitioner, or

Clinical Nurse Specialist

85% of 16% of fee schedule allowance

34

Managing Modifiers 80 vs. AS

Stay informed on modifier guidelines for surgical assistants

Outline modifiers appropriate to report for services performed in your

practice

Ensure NPP assistant services billed are submitted under the NPP’s

name and number

Review statements/surgical assistant denials

Articles addressing appropriate use

http://medicare.fcso.com/Fee_resources/238063.asp

35

19

Multiple, Bilateral, Endoscopic

Reimbursement Methodology

36

Multiple Surgery

Multiple surgeries – same day/same physician

Medicare Physician Fee Schedule payment policy indicator “2” –

multiple surgery applies

Reimbursement

Based on approved amount, not billed amount

Bill same day surgery procedures on same claim

37

Procedure Allowed Amount

1st 100% of fee schedule

allowance

2nd – 5th 50% of fee schedule

allowance

6 or more By report

20

Reimbursement Example

38

Procedure

Code

MPFSDB

Indicator

Billed

$

Medicare

Allowed

$

Ranking Medicare

Paid

$

35301 2 2,000 1262.54 100%

1262.54

X 80%

35201 2 1,200 1118.13 50% 559.06

X 80%

35261 2 1,300 1260.12 50% 630.06

X 80%

Bilateral Surgery

Do Not report 50

Code definition contains the term “bilateral” or “unilateral or

bilateral”

Based on 100% of the fee schedule

Do report 50

Procedures not identified in their descriptor as bilateral.

Report procedure on one detail line with modifier 50

or

Report the same procedure on separate lines with

modifier LT or RT

Based on 150% of the fee schedule

39

21

Reimbursement Example

Procedure

Code

MPFSDB

Indicator

(50 modifier)

Unilateral

Allowed

$

Medicare Paid

$

66984-50 1 729.69 x 150%

= 1094.54

(bilateral)

1094.54 X 80%

40

Endoscopic Procedures

Payment policy indicator “3” in MPFSDB

Endoscopic procedures

Same family

Share same base code

Special reimbursement rules apply

Different family

Do not share same base code

Standard payment adjustment rules

41

22

Reimbursement Example

Procedure

codes

(Same

Family)

Base Code MPFSDB

Indicator

Medicare

Allowed

$

Medicare

Paid

$

45307 45300 3 118.71 118.71 x 80%

45305 45300 3 90.58

90.58 – 60.70

= 29.88

29.88 X 80%

Base Endoscopy

45300 2 60.70 Used for

calculation

purposes 42

43

Resources

23

44

First Coast Service Options Inc.

medicare.fcso.com

medicareespanol.fcso.com

First Coast Resources

Article on appropriate use of assistant at surgery modifiers

http://medicare.fcso.com/Fee_resources/238063.asp

Definitions of Medicare physician fee schedule indicators

http://medicare.fcso.com/Fee_lookup/fee_schedule.asp

Fee schedule look up

http://medicare.fcso.com/Fee_lookup/fee_schedule.asp

Medical documentation webpage

http://medicare.fcso.com/Landing/179638.asp

Modifier FAQs

http://medicare.fcso.com/FAQs/138438.asp

Modifier Flowcharts (24, 25, 57, 58, 78, 79)

http://medicare.fcso.com/Landing/234002.asp

45

24

First Coast Resources

Web-Based Trainings (WBTs):

Modifiers

24

25

58

78

79

Introduction to Global Surgery

Medical Documentation Errors

Medical Documentation Request

www.FCSOUniversity.com

46

47

Centers for Medicare & Medicaid

Services

www.cms.gov

25

CMS Resources

Internet Only Manuals (IOMs) Publication 100-04, Chapter 12

Section 40: Surgeons and Global Surgery

http://www.cms.gov/manuals/downloads/clm104c12.pdf

Physician fee schedule

https://www.cms.gov/apps/physician-fee-schedule/

48

Question & Answer Session

What questions do you have?

49

26

Summary of Topics

Today we learned how to • Recognize components of the global surgical package

• Apply appropriate modifiers pertaining to global surgery

• Identify correct billing and reimbursement methods

• Review information within the Medicare Physician Fee Schedule Data Base

• Locate resources to assist in understanding global surgery rules

50

Thank You for Participating

First Coast values your feedback It is important that you complete the evaluation form and return it

before leaving the class

51