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Medifest 2013
Global Surgery:
Dissecting the Guidelines March 13, 2013
Proprietary and Confidential
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Presented By
First Coast Service Options, Inc.
Provider Outreach & Education
Cara Page
Provider Relations Representative
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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.
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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
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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
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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
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Global Surgery
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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
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Global Surgery Concept
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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)
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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
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Services Not Included
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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
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Medicare Physician Fee Schedule
Data Base
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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
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Payment Policy Indicators
Billing Requirements
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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
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Billing Guidelines
Surgery Modifiers
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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
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Surgery Modifier
Exercises
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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?
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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?
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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?
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Evaluation and Management
Modifiers
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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
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E/M Modifier
Exercises
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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?
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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?
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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?
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Split Care
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How to Bill Transfer of Care
Modifier 56: pre-operative management only
Modifier 54: surgical care only
Modifier 55: post-operative management only
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Split Care Billing
Scenarios
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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.
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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.
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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)
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Surgical Assistant
vs.
Assistant at Surgery
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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
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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
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Multiple, Bilateral, Endoscopic
Reimbursement Methodology
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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
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Procedure Allowed Amount
1st 100% of fee schedule
allowance
2nd – 5th 50% of fee schedule
allowance
6 or more By report
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Reimbursement Example
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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
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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%
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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
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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
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Resources
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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
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First Coast Resources
Web-Based Trainings (WBTs):
Modifiers
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Introduction to Global Surgery
Medical Documentation Errors
Medical Documentation Request
www.FCSOUniversity.com
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Centers for Medicare & Medicaid
Services
www.cms.gov
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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/
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Question & Answer Session
What questions do you have?
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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
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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
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