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Chapter 29: Surgery Services


Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims



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Effective July 1, 2012

Complete Chapter for printing

Look for possible updates and corrections to these payment policies

 

Table of contents

Definitions

Payment policies:
Autologous chondrocyte implant (ACI)
Angioscopy
Bilateral surgeries
Bone growth stimulators
Bone morphogenic protein
Closure of enterostomy
Endoscopy procedures
Epidural adhesiolysis
Global surgery
Meniscal allograft transplantation
Microsurgery
Minor surgical procedures
Pre, intra, or postoperative services
Procedures performed in a physician’s office
Registered nurses as surgical assistants
Standard multiple surgeries


More info:
Related topics


Definitions

Certified or accredited facility or office:

L&I defines a certified or accredited facility or office that has certification or accreditation from one of the following organizations:

  • Medicare (CMS – Centers for Medicare and Medicaid Services),
  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO),
  • Accreditation Association for Ambulatory Health Care (AAAHC),
  • American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF),
  • American Osteopathic Association (AOA),
  • Commission on Accreditation of Rehabilitation Facilities (CARF).

CPT® and HCPCS code modifiers mentioned in this chapter:

–22

Unusual services

Procedures with this modifier may be individually reviewed prior to payment.  A report is required for this review.  Payment varies based on the report submitted.

–24

Unrelated evaluation and management (E/M) services by the same physician during a postoperative period

Used to indicate an evaluation and management service unrelated to the surgical procedure was performed during a postoperative period.  Documentation must be submitted with the billing form when this modifier is used.  Payment is made at one hundred percent of the fee schedule level or billed charge, whichever is less.

–25

Significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure

Payment is made at 100% of the fee schedule level or billed charge, whichever is less.

–26

Professional component

Certain procedures are a combination of the professional (-26) and technical (-TC) components.  This modifier should be used when only the professional component is performed.  When a global service is performed, neither the -26 nor the -TC modifier should be used. (See above for information on the use of the -TC modifier.)

-50

Bilateral surgery

The bilateral modifier identifies cases where a procedure typically performed on one side of the body is, in fact, performed on both sides of the body.  Payment is made at one hundred fifty percent of the global surgery fee for the procedure.  Providers must bill using two line items on the bill form.  The modifier -50 should be applied to the second line item.

-51

Multiple surgeries

For procedure codes that represent multiple surgical procedures, payment is made based on the fee schedule allowance associated with that code.  Refer to the global surgery rules for additional information.

–54

Surgical care only (see Note, below)

When one physician performs a surgical procedure and another provides preoperative and/or postoperative management.

–55

Postoperative management only (see Note, below)

When one physician performs the postoperative management and another physician has performed the surgical procedure.

–56

Preoperative management only (see Note, below)

When one physician performs the preoperative care and evaluation and another physician performs the surgical procedure.

Note: When providing less than the global surgical package, providers should use modifiers –54, –55, and –56.  These modifiers are designed to ensure that the sum of all allowances for all providers doesn’t exceed the total allowance for the global surgery period.  These modifiers allow direct payment to the provider of each portion of the global surgery services.

–57

Decision for surgery

Used only when the decision for surgery was made during the preoperative period of a surgical procedure with a global surgery follow-up period.  It shouldn't be used with visits furnished during the global period of minor procedures (0-10 day global period) unless the purpose of the visit is a decision for major surgery.  Separate payment should be made even if the visit falls within the global surgery period.  No separate documentation is needed when submitting a billing form with this modifier.

–58

Staged or related procedure or service by the same physician during the postoperative period

Used to report a surgical procedure that is staged or related to the primary surgical procedure and is performed during the global period.

–62

Two surgeons

For surgery requiring the skills of two surgeons (usually with a different specialty), each surgeon is paid at 62.5% of the global surgical fee.  No payment is made for an assistant-at-surgery in these cases.

–66

Team surgery

Used when highly complex procedures are carried out by a surgical team.  This may include the concomitant services of several physicians, often of different specialties, other highly skilled, specially trained personnel, and various types of complex equipment.  Procedures with this modifier are reviewed and priced on an individual basis.  Supporting documentation is required for this review.

–78

Return to the operating room for a related procedure during the postoperative period

Payment is made at one hundred percent of the fee schedule level or billed amount, whichever is less.

–79

Unrelated procedure or service by the same physician during the postoperative period

Use of this modifier allows separate payment for procedures not associated with the original surgery.  Payment is made at one hundred percent of the fee schedule level or billed amount, whichever is less.

–80

Assistant surgeon (see below)

–81

Minimum assistant surgeon (see below)

–82

Assistant surgeon (when qualified resident surgeon not available)

Assistant surgeon modifiers.

Physicians who assist the primary physician in surgery should use modifiers –80, –81, or –82 depending on the medical necessity.  Payment for procedures with these modifiers is made at the billed charge or twenty percent of the global surgery amount for the procedure, whichever is less.  Refer to the assistant surgeon indicator in the Professional Services Fee Schedule to determine if assistant surgeon fees are payable.

–SU

Procedure performed in physician’s office

Denotes the use of facility and equipment while performing a procedure in a provider’s office.

–TC

Technical component

Certain procedures are a combination of the professional (—26) and technical (—TC) components.  This modifier should be used when only the technical component is performed.  When a global service is performed, neither the —26 nor the —TC modifier should be used.  (See above for information on the use of the —26 modifier.)

Endoscopy:

For the purpose of these payment policies, “endoscopy” will be used to refer to any invasive procedure performed with the use of a fiberoptic scope or other similar instrument.


Payment policy: Autologous chondrocyte implant (ACI)

Prior authorization

Autologous chondrocyte implant (ACI) requires prior authorization.  The insurer may cover ACI when all of the guidelines are met.  In addition to the clinical guidelines for the procedure, the surgeon must:

  • Have received training through Genzyme Biosurgery, and
  • Have performed or assisted with 5 ACI procedures, or
  • Perform ACI under the direct supervision and control of a surgeon who has performed 5 or more ACI procedures.

If the procedure is authorized, the insurer will pay US Bioservices for Carticel® (autologous cultured chondrocytes).

For more information, go to
www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/autologouschondrocyteimplant.asp

Services that can be billed

CPT® code for the implant is 27412. 
CPT® code 29870 for harvesting the chondrocytes.


Payment policy: Angioscopy

Payment limits

Payment for angioscopies CPT® code 35400 is limited to only one unit based on its complete code description encompassing multiple vessels.

Note: The work involved with varying numbers of vessels was incorporated in the RVUs.


Payment policy: Bilateral surgeries

Requirements for billing

Bilateral surgeries should be billed as two line items:

  • Modifier –50 must be applied to the second line item, and
  • The second line item is paid at the lesser of the billed charge, or 50% of the fee schedule maximum.

Bilateral surgeries are considered one procedure when determining the highest valued procedure before applying multiple surgery rules.

To see if modifier –50 is valid with the procedure performed, check the Professional Services Fee Schedule at www.Lni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2012FS/fsAll.xls

Example 1: Billing for bilateral surgeries

Line item CPT® code(and modifier) Maximum payment (nonfacility setting) Bilateral policy applied Allowed amount
1 64721 $709.46 $709.46 (1)
2 64721-50 $709.46 $354.73 (2) $354.73
Total allowed amount in nonfacility setting: $1,064.13 (3)

(1)   Allowed amount for the highest valued procedure is the fee schedule maximum.
(2)   When applying the bilateral payment policy, the two line items will be treated as one procedure. The second line item billed with a modifier –50 is paid at 50% of the value paid for the first line item.
(3)   Represents total allowable amount.


Example 2: Billing for bilateral surgeries and multiple procedures

Line item CPT® code (and modifier) Max payment (nonfacility setting) Bilateral policy applied Multiple procedure policy applied Allowed amount
1 63042 $2,141.10 $2,068.61 (1)
2 63042-50 $2,141.10 $1,070.55 (2) $1,070.55
Subtotal: $3,139.16 (3)
3 22612-51 $2,623.12 $1,311.56 (4) $1,311.56
Total allowed amount in nonfacility setting: $4,450.72 (5)

(1)   Allowed amount for the highest valued procedure is the fee schedule maximum.
(2)   When applying the bilateral payment policy, the two line items will be treated as one procedure. The second line item billed with a modifier –50 is paid at 50% of the value paid for the first line item.
(3)   The combined bilateral allowed amount is used to determine the highest valued procedure when applying the multiple surgery rule.
(4)   The third line item billed with modifier –51 is paid at 50% of the maximum payment.
(5)   Represents total allowable amount.

Payment policy: Bone growth stimulators

Prior authorization

These HCPCS (billing) codes for bone growth stimulators require prior authorization:

  • E0747 (Osteogenesis stimulator, electrical, noninvasive, other than spinal application), and
  • E0748 (Osteogenesis stimulator, electrical, noninvasive, spinal application), and
  • E0749 (Osteogenesis stimulator, electrical (surgically implanted)), and
  • E0760 (Osteogenesis stimulator, low intensity ultrasound, noninvasive).

The insurer, with prior authorization, pays for bone growth stimulators for specific conditions when proper and necessary, including:

  • Noninvasive or external stimulators including those that create a small electrical current and those that deliver a low intensity ultrasonic wave to the fracture, and
  • Implanted electrical stimulators that supply a direct current to the bone.

Link: For more information, go to
              www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/bonegrowthstimulators.asp


Payment policy:Bone morphogenic protein

Prior authorization

The insurer may cover the use of bone morphogenic protein as an alternative to autograft in recalcitrant long bone nonunion where use of autograft isn’t feasible and alternative treatments have failed.  It may also cover its use for spinal fusions in patients with degenerative disc disease at one level from L4-S1.

All of the criteria and guidelines must be met before the insurer will authorize the procedures.

Link: For more information, go to
              www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/bonemorphogenics.asp

In addition, lumbar fusion guidelines must be met.

Link: For more information, go to www.Lni.wa.gov/ClaimsIns/Providers/Treatment/TreatGuide/default.asp

Requirements for billing

CPT® codes used depend on the specific procedure being performed.



Payment policy: Closure of enterostomy

Payment limits

Closures of enterostomy aren’t payable with mobilization (take down) of splenic flexure performed in conjunction with partial colectomy.

CPT® code 44139 will be denied if it is billed with CPT® code 44625 or 44626.

Payment policy: Endoscopy procedures

(See definition of endoscopy in “Definitions” at the beginning of this chapter.)

Endoscopy family groupings

Endoscopy procedures are grouped into clinically related families.  Each endoscopy family contains a base procedure that is generally defined as the diagnostic procedure (as opposed to a surgical procedure).

The base procedure for each code belonging to an endoscopy family is listed in the “Endo Base” column in the Professional Services Fee Schedule.

Link: For more information, go to the Professional Services Fee Schedule at www.Lni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2012FS/fsAll.xls

Base procedures and their family members are also identified in Appendix A, Endoscopy Families.

Link: For more information on “Endoscopy Families,” see Payment Policies: Appendix A.

How multiple endoscopy procedures pay

When multiple endoscopy procedures belonging to the same family (related to the same base procedure) are billed, maximum payment is calculated as follows:

  • The endoscopy procedure with the highest dollar value is 100% of the fee schedule value, then
  • For subsequent endoscopy procedures, payment is the difference between the family member and the base fee (see Example 1, below), then
  • When the maximum fee for the family member is less than the maximum base fee, the payment is $0.00 for the family member (see Example 2, below), then
  • No additional payment is made for a base procedure when a family member is billed.

Once payment for all endoscopy procedures is calculated, each family is defined as an endoscopic group.

If more than one endoscopic group or other non-endoscopy procedure is billed for the same patient on the same day by the same provider, the standard multiple surgery policy will be applied to all procedures (see Examples 3 and 4, below).

Multiple endoscopies that aren’t related (each is a separate and unrelated procedure) are priced as follows:

  • 100% for each unrelated procedure, then
  • Apply the standard multiple surgery policy.

Payment limits

Payment isn’t allowed for an E/M office visit on the same day as a diagnostic or surgical endoscopic procedure unless:

  • A documented, separately identifiable service is provided, and
  • Modifier –25 is used.

Example 1: Billing for two endoscopy procedures in the same family

Line item CPT® code Maximum payment
(nonfacility setting)
Endoscopy policy applied Allowed
amount
Base (1) 29805 $779.19 $0.00 (2)
1 29820 $892.08 $112.89 (4) $112.89 (5)
2 29824 $1,118.97 $1,118.97 (3) $1,118.97 (5)

Total allowed amount in nonfacility setting:

$1,231.86 (6)

(1)  Base code listed is reference only (not included on bill form).
(2)  Payment isn’t allowed for a base code when a family member is billed.
(3)  Allowed amount for the highest valued procedure in the family is the fee schedule maximum.
(4)  Allowed amount for other procedures in the same endoscopy family is calculated by subtracting the fee schedule maximum for the base code from the fee schedule maximum for the nonbase code.
(5)  Amount allowed under the endoscopy policy.
(6)  Represents total allowed amount after applying all applicable global surgery policies.  Standard multiple surgery policy doesn’t apply because only one family of endoscopic procedures was billed.

Example 2: Billing for endoscopy family member with fee less than base procedure

Line item CPT® code Maximum payment (nonfacility setting) Endoscopy policy applied Allowed amount
Base (1) 43235 $511.34
1 43241 $261.20 $0.00 (2)  
2 43251 $364.69 $364.69 (3) $364.69 (4)
Total allowed amount in nonfacility setting: $364.69 (5)

(1)   Base code listed is for reference only (not included on bill form).
(2)   Allowed amount for the highest valued procedure in the family is the fee schedule maximum.
(3)   When the fee schedule maximum for a code in an endoscopy family is less than the fee schedule maximum for the base code, no add-on will be provided nor will there be a reduction in payment.  Consider the portion of payment for the lesser family member equal to $0.00.
(4)   Allowed amount under the endoscopy policy.
(5)   Represents total allowed amount.  Standard multiple surgery policy doesn’t apply because only 1 endoscopic group was billed.


 

Example 3: Billing for two surgical procedures billed with an endoscopic group (highest fee)

Line item CPT® code Maximum payment(nonfacility setting) Endoscopy policy applied Standard multiple surgery policy applied
1 11402 $274.49 $137.25 (5)
2 11406 $509.13 $254.57 (5)
Base (1) 29830 $750.41
3 29835 $835.63 $85.22 (3) $85.22 (4)
4 29838 $977.30 $977.30 (2) $977.30 (4)
Total allowed amount in nonfacility setting: $1,454.34 (6)

(1)   Base code listed is for reference only (not included on bill form).
(2)   Allowed amount for the highest valued endoscopy procedure is the fee schedule maximum.
(3)   Allowed amount for the second highest valued endoscopy procedure in the family is calculated by subtracting the fee schedule maximum for the base code from the fee schedule maximum for the nonbase code.
(4)   Standard multiple surgery policy is applied, with the highest valued surgical procedure or endoscopy group being paid at 100%.
(5)   Standard multiple surgery policy is applied, with the second and third highest valued surgical procedures being paid at 50% each.
(6)   Represents total allowed amount after applying all applicable global surgery policies.


 

Example 4: Billing for one surgical procedure (highest fee) billed with an endoscopic group

Line item CPT® code Maximum payment (nonfacility setting) Endoscopy policy applied Standard multiple surgery policy applied
1 23412 $1,408.96   $1,408.96 (4)
Base (1) 29805 $779.19    
2 29820 $892.08 $112.89(3) $56.45 (5)
3 29824 $1,118.97 $1,118.97 (2) $559.49 (5)
Total allowed amount in nonfacility setting: $2,024.90 (6)

(1)   Base code listed is for reference only (not included on bill form).
(2)   Allowed amount for the highest valued endoscopy procedure is the fee schedule maximum.
(3)   Allowed amount for the second highest valued endoscopy procedure in the family is calculated by subtracting the fee schedule maximum for the base code from the fee schedule maximum for the nonbase code.
(4)   Standard multiple surgery policy is applied, with the highest valued surgical procedure or endoscopy group being paid at 100%.
(5)   Standard multiple surgery policy is applied, with the second and third highest valued surgical procedures being paid at 50% each.
(6)     Represents total allowed amount after applying all applicable global surgery policies.


Payment policy: Epidural adhesiolysis

Prior authorization

The insurer, with prior authorization, pays for epidural adhesiolysis using the one day protocol but doesn’t pay for the 3 day protocol.

Note: Epidural adhesiolysis is also known as:

  • Percutaneous lysis of epidural adhesions, or
  • Epidural decompressive neuroplasty, or
  • Racz neurolysis.

Workers must meet the following criteria:

  • The worker has experienced acute low back pain or acute exacerbation of chronic low back pain of no more than 6 months duration, and
  • The provider intends to conduct the adhesiolysis in order to administer drugs closer to a nerve, and
  • The provider documents strong suspicion of adhesions blocking access to the nerve, and
  • Adhesions blocking access to the nerve have been identified by Gallium MRI or Fluoroscopy during epidural steroid injections.

Link: For more information, go to
              www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/Epiduraladhesiolysis.asp


Payment policy: Global surgery

Global surgery follow-up periods

Many surgeries have a follow-up period during which charges for normal postoperative care are bundled into the global surgery fee.

The global surgery follow-up period for each surgery is listed in the “Follow-Up” column in the Professional Services Fee Schedule.

What is included in the follow-up period

The follow-up period always applies to the following CPT® codes, unless modifier –22, –24, –25, –57, –58, –78, or –79 is appropriately used:

  • E/M codes:
    • 99211-99215, and
    • 99218-99220, and
    • 99231-99239, and
    • 99291-99292, and
    • 99304-99310, and
    • 99315-99318, and
    • 99334-99337, and
    • 99347-99350, and
  • Ophthalmological codes: 92012-92014

The following services and supplies are included in the global surgery follow-up period and are considered bundled into the surgical fee:

  • The operation itself, and
  • Preoperative visits, in or out of the hospital, beginning on the day before the surgery, and
  • Services by the primary surgeon, in or out of the hospital, during the postoperative period, and
  • The following services:
    • Dressing changes, and
    • Local incisional care and removal of operative packs, and
    • Removal of cutaneous sutures, staples, lines, wires, tubes, drains, and splints, and
    • Insertion, irrigation and removal of urinary catheters, routine peripheral IV lines, nasogastric, and rectal tubes, and
    • Change and removal of tracheostomy tubes, and
    • Cast room charges.
  • Additional medical or surgical services required because of complications that don’t require additional operating room procedures.

What isn’t included in the follow-up period

The following services and supplies aren’t included in the global surgery follow-up period:

  • Casting materials aren’t part of the global surgery policy and are paid separately, and
  • The initial consultation or evaluation by the surgeon to determine the need for surgery, and
  • Services of other providers except where the surgeon and the other provider(s) agree on the transfer of care, and
  • Visits unrelated to the diagnosis of the surgical procedure performed, unless the visits occur due to surgery complications, and
  • Treatment for the underlying condition or an added course of treatment which isn’t part of the normal surgical recovery, and
  • Diagnostic tests and procedures, including diagnostic radiological procedures, and
  • Distinct surgical procedures during the postoperative period which aren’t re-operations or treatment for complications, and

Note: A new postoperative period begins with the subsequent procedure.

  • Treatment for postoperative complications which requires a return trip to the operating room, and
  • Immunotherapy management for organ transplants, and
  • Critical care services (CPT® codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the provider, and
  • If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.

Who must perform these services to qualify for payment

The follow-up period applies to any provider who participated in the surgical procedure. These providers include:

  • Surgeon or physician who performed any component of the surgery (The pre, intra, and/or postoperative care of the patient; identified by modifiers –56, –54, and –55), and
  • Assistant surgeon (identified by modifiers –80, –81, and –82), and
  • Two surgeons (identified by modifier –62), and
  • Team surgeons (identified by modifier –66), and
  • Anesthesiologists and CRNAs.

Payment limits

Professional inpatient services (CPT® codes 99211-99223) are only payable during the follow-up period if they are performed on an emergency basis.

Example: They aren’t payable for scheduled hospital admissions.

Codes that are considered bundled aren’t payable during the global surgery follow-up period.


Payment policy: Meniscal allograft transplantation

Prior authorization

With prior authorization, the insurer may cover meniscal allograft transplantation when all of the guidelines are met.

In addition to the clinical guidelines for the procedure, the surgeon must:

  • Have performed or assisted with 5 meniscal allograft transplants, or
  • Perform the transplant under the direct supervision and control of a surgeon who has performed 5 or more transplants.

Link: For more information, go to www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/CovMedDev/SpecCovDec/Meniscal.asp


Payment policy: Microsurgery

Services that can be billed

CPT® code 69990 is an add-on surgical code that indicates an operative microscope has been used.  As an add-on code, it isn’t subject to multiple surgery rules.

Payment limits

CPT® code 69990 isn’t payable when:

  • Using magnifying loupes or other corrected vision devices, or
  • Use of the operative microscope is an inclusive component of the procedure, (for example the procedure description specifies that microsurgical techniques are used), or
  • Another code describes the same procedure being done with an operative microscope.

Example: CPT® code 69990 can’t be billed with CPT® code 31535 because CPT® code 31536 describes the same procedure using an operating microscope.  (See below for a complete list of all such codes.)

These CPT® codes aren’t allowed with CPT®69990:

  • 15756-15758, or
  • 15842, or
  • 19364, or
  • 19368, or
  • 20955-20962, or
  • 20969-20973, or
  • 26551-26554, or
  • 26556, or
  • 31526, or
  • 31531, or
  • 31536, or
  • 31541-31546, or
  • 31561, or
  • 31571, or
  • 43116, or
  • 43496, or
  • 49906, or
  • 61548, or
  • 63075-63078, or
  • 64727, or
  • 64820-64823, or
  • 65091-68850.

Payment policy: Minor surgical procedures

Services that can be billed

For minor surgical procedures, the insurer only allows payment for an E/M office visit during the global period when:

  • A documented, unrelated service is furnished during the postoperative period and modifier –24 is used, or
  • The provider who performs the procedure is seeing the patient for the first time an initial new patient E/M service can be billed (also see “Requirements for billing,” below).

Services that aren’t covered

Modifier –57, decision for surgery, isn’t payable with minor surgeries.  When the decision to perform the minor procedure is made immediately before the service, it is considered a routine preoperative service and a visit or consultation isn’t paid in addition to the procedure.

Note: Also see “Payment limits,” below.

Requirements for billing

When the provider who performed the minor surgical procedure is seeing the patient for the first time bills an initial new patient E/M service:

  • This is considered a significant, separately identifiable service, and
  • Modifier –25 must be used, and
  • Appropriate documentation must be made in the chart describing the E/M service.

Payment limits

Modifier –57 is payable with an E/M service only when the visit results in the initial decision to perform major surgery.

Note: Also see “Services that aren’t covered,” above.

Payment policy: Pre, intra, or postoperative services

Services that can be billed

The insurer will allow separate payment when different providers perform the preoperative, intraoperative, or postoperative components of the surgery.

Note: Also see “Requirements for billing,” below.

Link: The percent of the maximum allowable fee for each component is listed in the Professional Services Fee Schedule, available at www.Lni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2012FS/fsAll.xls

Requirements for billing

When different providers perform preoperative, intraoperative, or postoperative components of the surgery, modifiers (–54, –55, or –56) must be used.

Note: Also see “Services that can be billed,” above.

If different providers perform different components of the surgery (pre, intra, or postoperative care), the global surgery policy applies to each provider.

Example: If the surgeon performing the operation transfers the patient to another provider for the postoperative care, the same global surgery policy, including the restrictions in the follow-up day period, applies to both providers.

Note: Also see the “Global surgery” payment policy earlier in this chapter.


 

Payment policy: Procedures performed in a physician’s office

Services that are covered

Procedures performed in a provider’s office are paid at nonfacility rates that include office expenses.

Services that aren’t covered

Services billed with modifier –SU aren’t covered.

Requirements for billing

Providers’ offices must meet ASC requirements to qualify for separate facility payments.

Link: For information about these requirements, see WAC 296-23B.


 

Payment policy: Registered nurses as surgical assistants

Who must perform these services to qualify for payment

Licensed registered nurses may be paid to perform surgical assistant services if they submit the following documents to L&I along with their completed provider application:

  • A photocopy of her/his valid and current registered nurse license, and
  • A letter granting on-site hospital privileges for each institution where surgical assistant services will be performed.

Payment limits

Payment for these services is 90% of the allowed fee that would be paid to an assistant surgeon.



Payment policy: Standard multiple surgeries

How multiple surgeries pay

When multiple surgeries are performed on the same patient at the same operative session or on the same day, the total payment equals the sum of:

100% of the global fee for the procedure or procedure group with the highest value, according to the fee schedule, and

50% of the global fee for the second through fifth procedures with the next highest values, according to the fee schedule.

When different types of surgical procedures are performed on the patient on the same day, the payment policies will always be applied in the following sequence:

  • Multiple endoscopy procedures, then
  • Other modifier policies, then
  • Standard multiple surgery policy.

Requirements for billing

More than five surgical procedures performed on the same patient on the same day require documentation and individual review to determine payment amount.

When the same surgical procedure is performed on multiple levels, each level must be billed as a separate line item.

Note: For additional instructions on billing bilateral procedures, see the payment policy on “Bilateral procedures” earlier in this chapter. 


If you’re looking for more information about… Then go here:
Administrative rules for Ambulatory Surgery Center (ASC) payment Washington Administrative Code (WAC) 296-23B:
http://app.leg.wa.gov/wac/default.aspx?cite=296-23B
Ambulatory Surgery Center Fee Schedule L&I’s website:
www.Lni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2012FS/fsAll.xls
Becoming an L&I Provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp
Billing instructions and forms Chapter 2:
Information for All Providers
Endoscopy family groupings Payment Policies Appendix A: Endoscopy Families
Professional Services Fee Schedules L&I’s website:
www.Lni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2012FS/fsAll.xls

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.


CPT® codes and descriptions only are © 2011 American Medical Association

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