Chapter 22
Global Surgery & Related Issues

22.1 Surgery

a. Multiple Surgeries

Multiple surgeries are separate procedures performed by a physician on the same patient at the same operative session or on the same day. Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. Intraoperative services, incidental surgeries or components of surgeries will not be separately reimbursed.

Reimbursement will be based on the following guidelines for multiple surgical procedures:
100% of the allowance for the highest valued procedure.
50% of the allowance for the second through the fifth highest valued procedures.
Effective for dates of service January 1, 1995 and after, the regular multiple surgery rules, as referenced above will be applied to the following procedure codes when billed for the same beneficiary on the same day, by the same physician:

Nuclear Medicine 78306, 78320, 78802-78803, 78806-78807

These pricing rules apply to dermatology services:
100% of the allowance for the highest valued procedure.
50% of the allowance for the
remaining procedures.
The Limiting Charge is 115% of the reduced payment amount for each procedure.

When more than five procedures are performed, reimbursement for the sixth and/or subsequent procedures will be reviewed on an individual consideration basis. Operative notes should be submitted with the claim when five or more surgical procedures are performed during the same operative session.

a.1 Reporting Guidelines:

Report the highest valued procedure.

Report additional surgical procedures with MODIFIER 51.

For example: If you are billing for a repair of a rotator cuff (Code 23412), and a ligament release (Code 23415), and a claviculectomy (Code 23120), report the codes as follows:
23412
23415 - 51
23120 - 51

If surgeons of different specialties are each performing a different procedure (with specific CPT codes) multiple surgery rules do not apply. If one of the surgeons performs multiple procedures, the multiple surgery rules apply to that physician's services.

b. Multiple Endoscopy Procedures

When multiple procedures are performed through the same endoscope, payment will be made for the highest valued endoscopy (100% of the allowance) plus the difference between the next highest and the base endoscopy.

c. Multiple Interventional Radiological Procedures

If multiple interventional radiological procedures are performed, both the radiology code and the primary surgical code are paid at 100% of the fee schedule. Subsequent surgical procedures will be reimbursed according to standard multiple surgery rules.

d. Global Surgical Package

The payment for a surgical procedure includes a standard package of preoperative, intraoperative, and postoperative services. The preoperative period included in the global fee for major surgery is 1 day. The postoperative period for major surgery is 90 days. The postoperative period for minor surgery is either 0 or 10 days depending on the procedure. For endoscopic procedures (except procedures requiring an incision), there is no postoperative period.

The Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery. The services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, physicians' offices. Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon. However, critical care services (99291 and 99292) are payable separately in some situations.

The following services are included in the payment amount for a global surgery:
Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;
Intraoperative Services - Intraoperative services that are normally a usual and necessary part of a surgical procedure;
Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room;
Postoperative Visits - Follow-up visits within the postoperative period of the surgery that are related to recovery from the surgery;
Postsurgical Pain Management - By the surgeon;
Supplies - Except for surgical trays for certain procedures in an office setting; and
Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
The following services
are not included in the payment amount for a global surgery:
The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery;

Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;
Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complication of the surgery;
Treatment for the underlying condition or an added course of treatment which is not part of the normal recovery from surgery;
Diagnostic tests and procedures, including diagnostic radiological procedures;
Clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment for complications (A new postoperative period begins with the subsequent procedure.) This includes procedures done in 2 or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. Examples of this are procedures to diagnose and treat epilepsy (codes 61533, 61534-61536, 61539, 61541, and 61543) which may be performed in succession within 90 days of each other.);
Treatment for postoperative complications which requires a return trip to the operating room (OR). An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient's condition was so critical there would be insufficient time for transportation to an OR);
If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;
For certain services performed in a physician's office, separate payment may be made for a surgical tray (code A4550);
Immunotherapy management for organ transplants; and
Critical care services (codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.
For minor surgeries and endoscopies, the Medicare program will not pay separately for an evaluation & management service on the same day as a minor surgery or endoscopy, unless a significant, separately identifiable service is also performed, for example, an initial consultation or initial new patient visit. As stated earlier, there is no postoperative period for endoscopic procedures (unless an incision is required) and minor surgical procedures have postoperative periods of 0 or 10 days, based on the procedure.

The Health Care Financing Administration has developed modifiers to bill for eligible services rendered in the pre- and postoperative periods of a surgery. These modifiers are: 22, 24, 25, 57, 58, 78, 79. The definitions of these modifiers, when and how they should be used, and some examples, are listed on the following pages:

22 - Unusual Procedural Services: When the service(s) provided is greater than what is usually required for the listed procedure, indicate this by adding modifier 22 to the procedure code. A report is also required.

For services on the physician fee schedule, modifier 22 is applicable only to those procedure codes for which the global surgery concept applies, whether the procedure code is surgical in nature or not. Supportive documentation, e.g., operative reports, progress notes, order sheets, pathology reports, etc., must be submitted with the claim.

Note: Modifier 22 will be removed when reported with procedures that do not have a global surgery period of 0, 10, or 90 days.

24 - Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier 24 to the appropriate level of E/M service.

An excision of a malignant lesion on the left arm is performed in the office on May 10, 1996. The ICD-9-CM diagnosis code reported is 171.2. The post-operative period designated for excision code 11606 is 10 days.

The patient returns to the office on May 15, 1996 and is treated for contact dermatitis, ICD-9-CM code 692.0. The physician should report the appropriate evaluation and management code followed by the 24 modifier, e.g., 9921224.

In order for the evaluation and management service to be payable in the postoperative period with the 24 modifier, the diagnosis code supporting the E/M service must be different from the diagnosis code reported for the previously performed surgery and, at times, additional documentation which would indicate the service was unrelated to the previous surgery must also be submitted.

Under certain conditions, physicians may need to report an E/M service with modifier 24 even though the diagnosis is the same as that reported for the surgery. In these instances, documentation should be included with the claim to help us determine payment eligibility. A narrative explanation which indicates the E/M service was unrelated to the previous surgery is acceptable documentation.

Modifier 24 should not be used for the medical management of a patient by the surgeon following surgery. Medicare recognizes modifier 24 only for the care following a discharge unless:
The care is for immunotherapy management furnished by the transplant surgeon;
The care is for critical care (99291, 99292) for a burn or trauma patient under diagnosis codes 800.0-929.9, 940.0-959.9; or
The documentation demonstrates that the visit occurred during a subsequent hospitalization and the diagnosis supports the fact that it is unrelated to the original surgery.
For minor surgeries and endoscopies, the Medicare program will not pay separately for a evaluation & management service on the same day as a minor surgery or endoscopy, unless a significant, separately identifiable service is also performed, for example, an initial consultation or initial new patient visit. As stated earlier there is no post-operative period for endoscopic procedures (unless an incision is required) and minor surgical procedures have post-operative periods ranging from 0 to 10 days, based on the procedure.

25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.

Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57.

Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed with the 25 modifier in addition to billing for suturing a scalp wound if a full neurological examination was made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status. In the circumstance when the decision to perform a minor procedure is typically done immediately before the service, (e.g., whether or not sutures are needed to close a wound, whether or not to remove a mole or wart, etc.) it is considered a routine preoperative service and a visit or consultation should not be reported in addition to the procedure.

Effective immediately for dates of service on or after January 1, 1997, separate payment may be made for an initial hospital visit (CPT codes 99221-99223), an initial inpatient consultation (CPT codes 99251-99255) and a hospital discharge service (CPT codes 99238 and 99239) when billed by the same physician for the same date as an inpatient dialysis service (CPT code 90935-90947). It is no longer required that these evaluation and management services be unrelated to the treatment of the patient's ESRD in order for payment to be made. However, the 25 modifier must still be reported with these evaluation and management services in order to indicate that they are significant and separately identifiable services. Physicians may request reviews of previously denied services.

57 - Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.

E/M services on the day before or on the day of major surgery ( 90 day global period) which result in the initial decision to perform the surgery are not included in the global surgery payment. These E/M services may be billed separately and identified with the 57 modifier.

This modifier should not be used for visits furnished during the global period of minor procedures (0 or 10 day global period ) unless the purpose of the visit is a decision for major surgery. This modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure. See modifier 25.

58 - Staged Procedure or Service by the Same Physician During the Postoperative Period: The physician may need 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; (b) more extensive than the original procedure; or (c) for therapy following a diagnostic surgical procedure. These circumstance may be reported by adding the modifier 58 to the staged procedure. A new postoperative period begins when the next procedure in the series is billed.

Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. (See modifier 78)

It would not be appropriate to report this modifier for codes which indicate in the terminology "one or more sessions", e.g., 66761, 67141, 67227. These codes are defined by CPT-4 as consisting of one or more sessions. The relative value units represent the work for the total number of sessions necessary for completion of the procedure. Therefore, subsequent sessions performed within the global period of the initial surgery are included in the global fee.

78 - Return to the Operating Room for a Related Procedure During the Postoperative Period: The physician may need 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 78 modifier to the related procedure.

When treatment for complications requires a return trip to the operating room, physicians must bill the CPT-4 code that describes the procedure (s) performed during the return trip. If no such code exists, use the unspecified procedure code in the correct series, e.g., 47999 or 64999. In this situation, you must include operative notes with the claim or a narrative description which will allow us to understand the extent of the service performed. The procedure code for the original surgery is not used except when the identical procedure is repeated.

An operating room for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient's condition was so critical there would be insufficient time for transportation to an operating room).

A partial colectomy is performed in the hospital on March 1, 1996. The postoperative designation for this procedure (code 44140) is 90 days.

On March 15, 1996, the patient is returned to the operating room for a secondary suture of the abdominal wall. This procedure should be reported as 4990078.

Note: Modifier 78 should not be used for services outside the global surgery period.

79 - Unrelated Procedure by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79.

A repair of a femoral hernia (49550) is performed on January 5, 1996. The postoperative period designation for this procedure code is 90 days.

On February 12, 1996, the same physician performs an appendectomy. The physician should report the appendectomy as 4495079.

d.1 Add-On Surgical Procedures

The Health Care Financing Administration has assigned various surgical procedures with global surgery post-operative periods of "ZZZ".

These procedures, while surgical in nature, are add-on codes that are always billed with another procedure. There is no post-operative work included in the fee schedule amount for "ZZZ" codes.

When billed independent of another qualifying service, "ZZZ" procedures will be denied since they, by definition, are not stand-alone procedures. When billed in conjunction with a primary surgical procedure or qualifying service, both the primary and add-on code will be paid. The global surgery rules will be applied to the primary procedure.

d.2 Splitting Post Operative Care

Specific billing guidelines must be followed when the surgical procedure and the post operative care is split between different physicians.

Modifiers 54 and 55 are used to indicate that the surgical care and post operative management services are being rendered by two different physicians. The physician who is rendering the one-day preoperative care, the intraoperative services, and any in-hospital visits bills his/her services with the date of the surgery, the procedure code for the surgery, and a 54 modifier to indicate that the bill is reflective only of the surgical care.

The physician rendering the postoperative, out of hospital care associated with a given surgical procedure should bill for his/her services with the date of the surgery, the procedure code for the surgery, and a 55 modifier. If the surgeon also cares for the patient for some period following discharge, the surgeon should bill the surgery with a 55 modifier and indicate the portion of the post-op care provided in addition to the surgery with a 54 modifier. (to
indicate the intra-operative service)

In those cases where the postoperative care is "split" between physicians, the billing for the postoperative care should be reported as follows:
Report the date of service using the date of the surgical procedure.
Report the procedure code for the surgical procedure, followed by modifier
55.
Report the range of dates that you provided the postoperative care in the procedure description (narrative) field on electronic claims, and block 19 on the HCFA-1500 claim form. We do not need each date; only the range of dates.
Both the surgeon and the physician(s) providing the post-operative care must keep a copy of the written transfer agreement in the beneficiary's medical records.
When transfer occurs, the receiving physician cannot bill for any part of the global services until at least one service has been provided. Once the physician has seen the patient, the physician may bill for the period beginning with the date care was assumed.
For example, a surgical procedure with 90 postoperative days was rendered on March 2, 1996 by Doctor Johnson. He continued to provide the postoperative care from the date of the patient's discharge, March 5, until April 5, 1996. Doctor Rose then assumed the patient's care and continued to provide the postoperative management until the end of the postoperative period. Each doctor would bill as follows:
Doctor Johnson:

Report the date of service as March 2, 1996 using the surgical procedure code, and modifier 54.

Report the charge for this service.

On the next line, report the same date of service, March 2, 1996, using the surgical procedure code and modifier 55. Report the charge for this service.

In the procedure description (narrative) field for electronic claims, or in block 19 of the HCFA 1500 claim form, report March 5 - April 5, 1996.

Doctor Rose:

Report the date of service as March 2, 1996 using the surgical procedure code and modifier 55.

In the procedure description (narrative) field for electronic claims, or in block 19 of the HCFA 1500 claim form, report April 6 - May 29, 1996.

When the postoperative care is split between two physicians, payment is based on the percentage of postoperative care that each provided.

e. Bilateral Procedures

1. Bilateral surgeries are defined as procedures performed on both sides of the body during the same operative session or on the same day. HCFA has defined codes subject to the bilateral payment rule. Payment for claims reporting bilateral procedures will be based on 150% of the fee schedule amount. The Limiting Charge is 115% of that amount.

2. Procedure codes containing the terms "bilateral" or "unilateral or bilateral" in their definitions are not subject to bilateral pricing. Payment for these services is based on 100% of the fee schedule for a surgical code. Procedure codes with terminology indicative of unilateral or bilateral services, as in code 27395 (lengthening of hamstring tendon; multiple, bilateral) or code 52290 (Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral) cannot be reported with the bilateral procedure code modifier 50 since the terminology for the code identifies the service as bilateral.

3. Certain procedures are not applicable to the 150% payment rule for bilateral procedures. Payment is based on 100% of the fee schedule for each side, e.g., codes 92225 and 92226. When performed bilaterally, these codes should be reported with modifiers RT-LT or modifier 50 to ensure proper payment.

e.1 Reporting Guidelines

Report the procedure code with MODIFIER 50.

Report a one in the number of services field.




For example: If you are billing for a bilateral mastectomy, you would report the service as a single line item: 19180 50

Reminder: Procedure codes with terminology indicative of unilateral or bilateral services, as in code 27395 (lengthening of hamstring tendon; multiple, bilateral) or code 52290 (Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral) cannot be reported with the bilateral procedure code modifier 50 since the terminology for the code identifies the service as bilateral and the reimbursement for the code includes the work associated with providing it bilaterally.

e.2 Bilateral Processing for Code 67820

Procedure code 67820, correction of trichiasis; epilation, by forceps only, is assigned a bilateral indicator of `0', indicating that bilateral rules do not apply. The selection of a bilateral indicator of `0' was intentional (not withstanding the bilateral nature of the services) because application of the bilateral payment policy would result in incorrect payment for the services when the service is performed on both the upper and lower lids of both eyes. One unit of CPT code 67820 has been valued based upon the physician work in removing the lashes from one lid (either the upper or lower) of one eye.

To allow for proper payment, physicians would bill two or more units of 67820 as multiple procedures, without regard to whether the units were performed on either the same or different eyes. In the case where a physician removes lashes from both the upper and lower lids of both eyes, the physician should bill 67820 on a single claim line showing 4 units of service and the multiple surgery modifier -51.

The multiple surgery rules, not the bilateral rules, will be applied to the 4 units of the code. Effective for dates of service January 1, 1995 and after, if these are the only multiple surgical procedures performed, 250% of the payment for one unit of the code will be allowed (100% + 50% + 50% + 50%). For dates of service prior to January 1, 1995, a total of 200% of the allowance for a single unit will be allowed (100% + 50% + 25% + 25%).

f. Assistant at Surgery

Some surgical procedures require a primary surgeon and an assistant surgeon. HCFA has identified those surgical procedures for which an assistant surgeon may be reimbursed. Payment will not be made for the services of assistants at surgery furnished in a teaching hospital which has a training program related to the medical specialty required for the surgical procedure and has a qualified resident available to perform the service.

Payment for an assistant surgeon is limited to 16% of the fee schedule amount for the surgical procedure. The Limiting Charge is 115% of the assistant surgeon's fee schedule amount.

f.1 Reporting Guidelines

Services for an assistant-at-surgery must be reported with one of the following modifiers as appropriate to the situation.

Modifier 80 - This modifier is reported when the services are performed in a non-teaching setting or in a teaching setting when a resident was available but the surgeon opted not to use the resident. In the latter case the service is generally not covered by Medicare unless the following circumstances exist and are reported on the claim form:
the primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative, or post operative care of his/her patients.
exceptional medical circumstances existed, e.g. emergency, life-threatening situations such as multiple traumatic injuries requiring immediate treatment.
Modifier
82 - This modifier is reported when there is no qualified resident surgeon available or when the services are performed in a teaching hospital that does not have an approved training program related to the medical specialty required for the surgical procedure.

f.2 Procedures Eligible for Assistant at Surgery for 1996

The Health Care Financing Administration has revised the list of surgical procedures which are eligible for assistant-at-surgery services. Please reference Appendix I for an eligible list of assistant-at-surgery services.

g. Co-Surgery

Under some circumstances, the individual skills of two surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient's condition. In these cases, the additional physician is not acting as an assistant-at-surgery.

Co-surgery refers to a single surgical procedure which requires the skill of two surgeons (usually with different skills) of the same or different specialties performing parts of the same procedure simultaneously, e.g., heart transplant or bilateral knee replacements. It is not always co-surgery when two doctors perform surgery on the same patient during the same operative session. Co-surgery has been performed if the procedure(s) performed is part of and would be billed under the same surgical code, (e.g., the excision of a pituitary tumor (CPT code 61548) by an otolaryngologist and a neurosurgeon). In this case, each physician reports code 61548 with the 62 modifier (two surgeons). Payment for each surgeon is 62.5% of the Medicare Fee Schedule amount.

Co-surgery has not been performed when each physician performed a separate surgical procedure which is reported under a different surgical procedure code, e.g., a hammertoe operation (CPT code 28285) performed by a podiatrist and a palma fasciotomy (CPT code 26040) performed by a hand surgeon. When two unrelated procedures are performed, each physician should bill for and be paid the full global fee for the procedure he/she performed.

g.1 Eligible Co-surgery Procedure Codes

There are 2 categories of surgical procedures for which co-surgery may be covered. Codes not listed as Category I or Category II are not eligible for reimbursement for co-surgery.

When performing co-surgery, it is important to communicate with the other surgeon's office to be certain that the claims are submitted properly.

g.1a Category I Procedure Codes

Listed below are codes which the Health Care Financing Administration has determined can be paid for co-surgery when an operative report supporting the need for co-surgeons (of the same or different specialties) is submitted with the claim. If the surgical procedures performed by each surgeon can be clearly identified, and each surgeon's role during the operative session is explicitly described, the same operative report may be submitted with each surgeon's claim. Otherwise, an operative report dictated by each physician is required. If an operative report(s) is not submitted the claim will be denied.

 

12007

12018

12037

12047

12057

15121

15732

15734

15736

15738

15770

15831

15832

15841

15842

15922

15935

15936

15937

15946

15951

15952

15953

15956

15958

15999

17999

19125

19126

19162

19180

19182

19200

19220

19240

19260

19271

19272

19316

19318

19340

19342

19357

19361

19364

19366

19367

19368

19369

19499

20150

20650

20692

20802

20805

20808

20816

20822

20824

20827

20838

20900

20902

20920

20922

20924

20931

20937

20938

20955

20956

20957

20962

20969

20970

20971

20973

20975

20999

21034

21044

21045

21060

21120

21123

21127

21138

21139

21141

21142

21143

21146

21154

21159

21172

21180

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21193

21196

21198

21206

21215

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21247

21255

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21267

21268

21270

21275

21299

21339

21343

21346

21347

21365

21385

21390

21395

21406

21407

21422

21433

21454

21461

21462

21465

21470

21490

21493

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21499

21557

21600

21615

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21632

21725

21740

21750

21825

21899

21935

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22101

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22110

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22116

22210

22214

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22220

22224

22226

22325

22326

22327

22328

22800

22802

22804

22808

22810

22812

22830

22840

22849

22850

22852

22855

22899

22900

22999

23000

23040

23044

23077

23100

23101

23105

23106

23107

23120

23125

23130

23145

23150

23155

23174

23180

23184

23190

23195

23200

23210

23220

23222

23332

23395

23397

23400

23405

23410

23412

23415

23420

23430

23440

23450

23455

23460

23462

23465

23466

23470

23472

23480

23485

23491

23515

23550

23552

23585

23615

23630

23660

23670

23680

23800

23802

23920

23929

24000

24077

24100

24102

24110

24115

24125

24130

24145

24147

24149

24150

24151

24152

24155

24160

24164

24301

24320

24340

24341

24342

24352

24360

24361

24365

24366

24400

24410

24420

24430

24435

24498

24515

24545

24575

24579

24586

24587

24615

24635

24665

24666

24685

24800

24900

24920

24999

25105

25107

25116

25119

25120

25135

25136

25150

25151

25170

25210

25215

25230

25240

25274

25280

25310

25312

25330

25331

25360

25375

25390

25391

25400

25405

25415

25420

25425

25426

25440

25441

25442

25443

25445

25446

25447

25449

25515

25545

25575

25670

25695

25800

25805

25810

25820

25825

25830

25999

26185

26255

26352

26390

26392

26477

26483

26485

26492

26494

26498

 

26499

26518

26525

26531

26540

26541

26553

26554

26556

26558

26559

26561

26665

26685

26820

26841

26842

26843

26844

26852

26862

27000

27001

27003

27005

27006

27025

27030

27033

27035

27036

27048

27049

27050

27052

27054

27062

27065

27066

27070

27071

27075

27076

27077

27078

27079

27080

27087

27090

27091

27100

27110

27111

27120

27122

27125

27130

27132

27134

27137

27138

27140

27146

27147

27151

27156

27161

27165

27170

27176

27177

27178

27185

27187

27235

27236

27244

27248

27253

27254

27258

27280

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27284

27286

27290

27295

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27303

27305

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27332

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27409

27418

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27441

27442

27443

27445

27446

27447

27448

27450

27454

27455

27457

27465

27466

27468

27470

27472

27475

27477

27486

27487

27488

27495

27506

27514

27519

27524

27536

27540

27556

27557

27566

27580

27590

27591

27592

27596

27598

27599

27600

27602

27606

27612

27615

27620

27625

27635

27637

27638

27640

27641

27645

27646

27650

27652

27654

27658

27659

27665

27675

27680

27681

27685

27686

27687

27690

27691

27692

27695

27696

27698

27700

27702

27704

27705

27707

27709

27712

27715

27720

27722

27724

27725

27727

27730

27742

27745

27756

27758

27766

27784

27792

27814

27822

27823

27832

27846

27848

27870

27871

27880

27881

27882

27886

27888

27889

27899

28020

28035

28046

28050

28052

28062

28086

28100

28104

28106

28110

28111

28112

28114

28118

28119

28120

28122

28130

28140

28173

28175

28200

28202

28208

28225

28238

28250

28260

28262

28285

28292

28293

28294

28296

28297

28298

28299

28300

28302

28304

28305

28306

28308

28310

28312

28315

28320

28322

28344

28415

28420

28445

28485

28555

28585

28615

28645

28705

28715

28725

28730

28735

28737

28740

28755

28760

28800

28899

29799

29804

29815

29819

29820

29821

29823

29825

29826

29834

29835

29836

29837

29843

29845

29870

29880

29884

29885

29887

29888

29889

29894

29895

29898

29909

30118

30150

30160

30999

31040

31075

31081

31084

31085

31087

31205

31225

31230

31299

31300

31360

31365

31367

31368

31370

31375

31380

31382

31390

31395

31420

31580

31582

31584

31587

31590

31595

31599

31601

31611

31750

31755

31760

31766

31770

31780

31781

31785

31786

31805

31899

32002

32035

32036

32095

32100

32110

32120

32124

32140

32141

32150

32151

32160

32200

32215

32220

32225

32310

32320

32402

32440

32442

32445

32480

32482

32484

32486

32488

32500

32501

32520

32522

32525

32540

32650

32651

32652

32653

32654

32655

32656

32657

32658

32659

32660

32661

32662

32663

32664

32665

32800

 

32815

32820

32851

32852

32853

32854

32900

32905

32906

32940

32999

33020

33025

33030

33031

33050

33120

33130

33241

33242

33243

33244

33245

33246

33247

33249

33250

33251

33253

33261

33300

33305

33310

33315

33320

33321

33322

33330

33332

33335

33400

33401

33403

33404

33405

33406

33412

33413

33414

33415

33416

33417

33420

33422

33425

33426

33427

33430

33460

33463

33464

33465

33468

33471

33474

33475

33476

33478

33500

33502

33503

33504

33505

33506

33542

33545

33600

33602

33606

33608

33610

33611

33612

33615

33617

33619

33641

33645

33647

33660

33665

33670

33681

33684

33688

33690

33692

33694

33697

33702

33720

33722

33730

33732

33736

33737

33750

33755

33762

33764

33766

33767

33770

33771

33774

33776

33778

33779

33780

33786

33788

33802

33803

33813

33814

33822

33824

33840

33845

33851

33853

33860

33861

33863

33870

33875

33877

33910

33915

33916

33917

33918

33919

33920

33922

33924

33935

33945

33970

33973

33999

34001

34051

34101

34111

34151

34201

34203

34401

34421

34451

34471

34501

34510

34520

34530

35001

35002

35005

35011

35013

35021

35022

35045

35081

35082

35091

35092

35102

35103

35111

35112

35122

35131

35132

35141

35142

35151

35152

35161

35162

35180

35182

35184

35188

35189

35190

35201

35206

35207

35211

35216

35221

35226

35231

35236

35241

35246

35251

35256

35261

35266

35271

35276

35281

35286

35301

35311

35321

35331

35341

35351

35355

35361

35363

35371

35372

35381

35390

35450

35452

35454

35456

35458

35459

35460

35472

35501

35506

35507

35508

35509

35511

35515

35516

35518

35521

35526

35531

35533

35536

35541

35546

35548

35549

35551

35556

35558

35560

35563

35565

35566

35571

35582

35583

35585

35587

35601

35606

35612

35616

35621

35623

35626

35631

35636

35641

35642

35645

35646

35650

35651

35654

35656

35661

35663

35665

35666

35671

35681

35691

35693

35694

35695

35700

35701

35721

35741

35761

35800

35820

35840

35860

35870

35875

35876

35901

35903

35905

35907

36299

36821

36825

36830

36832

36834

37140

37160

37180

37181

37250

37251

37565

37600

37605

37607

37615

37616

37617

37618

37620

37650

37660

37720

37730

37735

37760

37780

37788

37799

38100

38101

38102

38115

38308

38380

38381

38382

38530

38542

38555

38562

38564

38700

38720

38724

38740

38745

38746

38747

38760

38765

38770

38780

38999

39000

39010

39200

39220

39499

39501

39502

39503

39520

39530

39531

39540

39541

39545

39599

40799

40899

41120

41130

41135

41140

41145

41150

41153

41155

41599

41899

42120

42299

42410

42415

42420

42425

42426

42440

42510

42699

42725

42815

42844

42845

42890

42892

42894

42950

42999

43020

43030

43045

43100

43101

43107

43108

43116

43122

43123

43124

43130

43135

43300

43305

43310

43312

43320

43324

43325

43326

 

43330

43331

43340

43341

43350

43351

43352

43360

43361

43400

43401

43405

43410

43415

43420

43425

43496

43499

43500

43501

43502

43510

43520

43605

43610

43611

43620

43621

43622

43631

43632

43633

43634

43635

43638

43639

43640

43641

43800

43810

43820

43825

43830

43831

43832

43840

43846

43847

43848

43850

43855

43860

43865

43870

43880

43999

44005

44010

44015

44020

44021

44025

44050

44055

44110

44111

44120

44121

44125

44130

44139

44140

44141

44143

44144

44145

44146

44147

44150

44151

44152

44153

44155

44156

44160

44300

44310

44314

44316

44320

44322

44340

44345

44346

44602

44603

44604

44605

44615

44620

44625

44640

44650

44660

44661

44680

44799

44800

44820

44850

44899

44900

44950

44955

44960

45108

45110

45111

45112

45113

45114

45116

45120

45121

45123

45130

45135

45160

45170

45190

45540

45541

45550

45560

45562

45563

45800

45805

45820

45825

45999

46705

46716

46730

46735

46740

46742

46744

46746

46748

46750

46751

46760

46761

46762

46999

47001

47010

47015

47100

47120

47122

47125

47130

47135

47136

47300

47350

47360

47361

47362

47399

47400

47420

47425

47460

47480

47550

47552

47554

47600

47605

47610

47612

47620

47630

47700

47711

47712

47715

47716

47720

47721

47740

47741

47760

47765

47780

47785

47800

47801

47802

47900

47999

48000

48001

48005

48020

48100

48120

48140

48145

48146

48148

48150

48152

48153

48154

48155

48180

48500

48510

48520

48540

48545

48547

48556

48999

49000

49002

49010

49040

49060

49085

49200

49201

49215

49220

49250

49255

49425

49495

49496

49500

49501

49505

49507

49520

49521

49525

49540

49550

49553

49555

49557

49560

49561

49565

49566

49568

49570

49572

49580

49582

49585

49587

49590

49600

49605

49606

49610

49611

49900

49906

49999

50010

50020

50040

50045

50060

50070

50075

50081

50100

50120

50125

50130

50135

50205

50220

50225

50234

50236

50240

50280

50290

50320

50340

50370

50380

50400

50405

50500

50520

50525

50540

50600

50605

50610

50620

50630

50650

50660

50700

50715

50722

50725

50740

50760

50770

50780

50785

50800

50810

50815

50820

50825

50830

50840

50845

50860

50900

50920

50930

50940

51020

51040

51050

51060

51080

51500

51520

51525

51530

51535

51550

51555

51565

51570

51575

51580

51585

51590

51595

51596

51597

51800

51820

51840

51841

51845

51860

51865

51880

51900

51920

51925

51940

51960

51980

53085

53210

53215

53230

53235

53400

53405

53410

53415

53420

53425

53430

53440

53443

53445

53447

53449

53510

53515

53899

54111

54112

54120

54125

54130

54300

54308

54312

54316

54318

54324

54326

54328

54332

54336

54340

54344

54348

54352

54360

54380

54385

54390

54400

54401

54402

54405

54407

54409

54440

54530

54560

54680

55150

55400

55520

55530

55535

55540

55650

55705

55720

 

55725

55801

55810

55812

55815

55821

55831

55840

55842

55845

55860

55862

55865

55870

55899

56316

56317

56320

56322

56323

56324

56340

56341

56342

56620

56625

56630

56640

56700

56800

56805

57108

57110

57120

57130

57200

57210

57220

57230

57240

57250

57260

57265

57268

57270

57280

57282

57288

57289

57292

57300

57305

57307

57310

57311

57320

57330

57335

57530

57540

57545

57550

57555

57556

58140

58145

58150

58152

58180

58200

58210

58240

58260

58267

58270

58275

58280

58285

58400

58410

58520

58600

58700

58720

58740

58750

58760

58805

58822

58825

58900

58920

58925

58940

58943

58950

58951

58952

58960

58974

58976

58999

59100

59120

59121

59514

59525

59866

59899

60200

60210

60212

60220

60225

60240

60252

60254

60260

60270

60271

60280

60281

60500

60502

60505

60512

60520

60521

60522

60540

60545

60600

60605

60699

61130

61150

61154

61156

61215

61250

61304

61305

61312

61313

61314

61315

61320

61321

61330

61332

61333

61334

61340

61343

61345

61440

61450

61458

61470

61480

61490

61500

61501

61510

61512

61514

61516

61518

61519

61521

61522

61524

61533

61534

61535

61536

61538

61539

61541

61542

61543

61545

61546

61550

61552

61559

61563

61564

61570

61571

61575

61576

61580

61581

61582

61583

61584

61585

61586

61590

61591

61592

61595

61596

61597

61598

61600

61601

61605

61606

61607

61608

61609

61610

61611

61612

61613

61615

61616

61618

61619

61680

61682

61684

61686

61690

61692

61700

61702

61703

61705

61711

61712

61735

61750

61751

61770

61865

61870

61880

62005

62010

62100

62115

62117

62120

62140

62141

62143

62145

62146

62147

62190

62192

62200

62220

62223

62230

62258

62350

62360

62361

62362

63055

63056

63057

63064

63066

63081

63082

63170

63172

63173

63180

63182

63185

63190

63191

63194

63195

63196

63197

63198

63199

63250

63251

63252

63265

63266

63267

63268

63270

63271

63272

63275

63276

63277

63278

63280

63281

63282

63283

63285

63286

63287

63290

63300

63301

63302

63303

63305

63306

63307

63615

63655

63660

63685

63700

63702

63704

63706

63707

63709

63710

63740

63741

63744

64590

64704

64708

64712

64713

64714

64716

64722

64746

64752

64755

64760

64763

64772

64782

64790

64792

64802

64804

64809

64818

64856

64857

64858

64859

64861

64864

64865

64866

64868

64870

64872

64874

64876

64885

64886

64892

64895

64896

64898

64901

64905

64907

64999

65091

65093

65103

65105

65110

65112

65114

65125

65130

65175

65265

65273

65290

65710

65730

65750

65755

65850

65865

65870

65875

65920

65930

66150

66160

66170

66172

66180

66220

66225

66500

66680

66852

66920

66940

66985

66986

66999

67005

67010

67015

67025

67030

67036

67038

67039

67040

67107

67108

67112

67120

67121

67250

67255

67299

67312

67318

67331

67332

67334

67335

 

67343

67399

67400

67412

67414

67420

67440

67445

67450

67550

67570

67599

67902

67903

67904

67950

67971

67973

67974

67999

68320

68325

68335

68362

68399

68525

68540

68720

68745

68750

68899

69150

69155

69399

69535

69554

69720

69799

69915

69949

69950

69955

69960

69970

69979

g.1b Category II Procedure Codes

Listed on the following page are codes which HCFA has determined can be paid for co-surgery. These codes do not require documentation of the medical necessity for co-surgery unless the co-surgery is performed by surgeons of the same specialty. If the co-surgeons are of the same specialty, operative reports must be submitted.

 

11303

15755

15756

15757

15758

19290

19291

21344

21348

21366

21408

21423

21436

22548

22554

22556

22558

22585

22590

22595

22600

22610

22612

22614

22630

22632

22842

22843

22844

22845

22846

22847

22848

22851

23616

24006

24516

24546

25520

25525

25526

25574

27193

27194

27215

27216

27217

27218

27226

27227

27228

27245

27496

27497

27498

27499

27507

27511

27513

27535

27558

27759

27826

27827

27828

27829

27892

27894

28531

28636

28666

29850

29851

29855

29856

30460

30462

31730

33206

33207

33208

33214

33236

33237

33238

33501

33800

35480

35481

35482

35483

35484

35485

35490

35491

35492

35493

35494

35495

37205

37206

37207

37208

43112

43113

43117

43118

43121

43246

43842

43843

49905

50230

50360

50365

50727

50728

50782

50783

56300

56301

56302

56303

56304

56305

56306

56307

56308

56309

56311

56312

56313

56315

56350

56351

56352

56353

56354

56355

56356

56405

56605

56606

56631

56632

56633

56634

56637

56810

57284

57460

58262

58263

58345

61460

61520

61526

61530

61531

61548

61760

62351

63001

63003

63005

63011

63012

63015

63016

63017

63020

63030

63035

63040

63042

63045

63046

63047

63048

63075

63076

63077

63078

63085

63086

63087

63088

63090

63091

h. Team Surgery

Team surgery also refers to a single procedure; however, it requires the skills of more than two surgeons of different specialties, working together to carry out various portions of a complicated surgical procedure. For example, a kidney transplant could involve the services of a general surgeon, a urologist and/or a vascular surgeon to remove the diseased kidney, to implant the donated kidney and to transplant the ureters.

HCFA has identified those services for which team surgeons may be paid. Payment for codes defined as eligible for team surgery will be reimbursed on an individual consideration basis. The Limiting Charge is 115% of the fee schedule distributive share for each of the team physicians.

h.1 Reporting Guidelines

Each surgeon should bill for the procedure using the modifier 66 (Team Surgery) following the procedure code. Sufficient documentation establishing the medical necessity of a team of surgeons must accompany each claim, e.g., operative notes.

22.2 Cardiac Catheterizations with Injection Procedures

Effective with the HCPCS update of 1994, only codes 93555 and 93556 are to be used for reporting the imaging supervision and interpretation (S&I) services in conjunction with the injection services described by CPT codes 93539 through 93544. The radiologic companion codes in the 75000 series are not to be used and claims processed after March 1, 1995 will be denied as billing errors when a 75000 series code is used to report the imaging supervision and interpretation of the injection procedures 93539 through 93545.

The following chart shows the appropriate S&I code(s) for each of the injection procedures.

 

Injection Procedure During
Cardiac Catheterization

Imaging Supervision &
Interpretation

93539

93555 and/or 93556

93540

93555 and/or 93556

93541

93555 and/or 93556

93542

93555

93543

93555

93544

93555 and/or 93556

93545

93555 and/or 93556


22.3 Payment Policy for Therapeutic Apheresis (36520)

Therapeutic apheresis is separately payable when billed in both a hospital and non-hospital setting. In addition, therapeutic apheresis (36520) will not be paid more than once per day when billed by the same physician for the same beneficiary.

However, payment for certain evaluation and management (E&M) procedure codes will be bundled into procedure code 36520 for services rendered on or after January 1, 1995. No payment will be made for the following E & M codes when billed with procedure code 36520:

99211-99215, 99231-99233, 99261-99263.