Reimbursements

Category:

Global Services and Subsequent Services

Reimbursement Policy:  NDRP-Surg-009     
Topic: Surgery
Effective Date: July 1, 2018
Last Reviewed:
March 1, 2019

 


Description:

This policy is to provide direction on The Plan’s reimbursement of global surgery services and subsequent hospital visits and hospital discharge day management services. Surgery is classified as either definitive/major or diagnostic/minor. Definitive/major surgical procedures have designated post-operative days (90 days) while diagnostic/minor surgical procedures have ten (10) or zero (0) post-operative days based on CMS Global Days.

Policy:

Pre and Post-operative Care

In-hospital, the allowance for a surgical procedure includes payment for routine in-hospital pre-operative care and routine post-operative care, in or out of the hospital, when provided by the surgeon, his assistant, or associate as defined by the CMS Global Days field (e.g. 0, 10, or 90 days).

*Other than in-hospital, the allowance for a surgical procedure, as defined by the CMS Global Days field (e.g. 0, 10, or 90 days), includes routine post-operative care when provided by the surgeon, his assistant, or associate.

*Note: As permitted under state license/accreditation and BCBSND policies.

Note: Reimbursement may be made for an unrelated Evaluation and Management (E/M) service by the same physician during the post-operative period when modifier 24 is reported with the E/M service.

Surgery and Medical Care on the Same Day

Regardless of place of service, medical care provided on the same day as a surgical procedure, as defined by the CMS Global Days field (e.g. 0, 10, or 90 days) by the same physician, for the same condition is not eligible for reimbursement.

An E/M visit is included in the global allowance for the surgery and not separately reimbursable and when the medical care is contractually excluded, the visit is not covered.

Note: Reimbursement may be made for a significant, separately identifiable E/M service by the same physician on the same day as defined by the CMS Global Days field (e.g. 0, 10, or 90 days) when modifier 25 is reported with the E/M code. When the 25 modifier is reported, the patients’ records must clearly document separately identifiable medical care was rendered. Modifier 25 should only be used on claims for E/M services, and only when these services are provided by the same physician (or same qualified non-physician practitioner) to the same patient on the same day as another procedure or other service. The plan will reimburse for an E/M service provided on the day of a procedure with a global fee period only when the physician indicates the service was for a significant, separately identifiable E/M service above and beyond the usual pre-and post- operative work of the procedure. Both the medically necessary E/M service and the procedure must be sufficiently documented in the patient’s medical record by the physician or other qualified non-physician practitioner to support the claim for these services.

Reimbursement may also be made for an E/M service that results in the initial decision to perform the surgery when modifier 57 is reported with the E/M code.

Procedures Reported with Modifier 78

Modifier 78 should be reported with procedure codes for treatment of postoperative complications that require a return trip to the operating room. An operating room is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term operating room 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.)

Note: A new Global Period will not apply to a procedure meeting these requirements and reported with modifier 78.

Cross Reference:

Refer to the following Reimbursement Policies for additional information:
Reimbursement Policy NDRP-GC-006: Modifiers 25, 59, XE, XP, XS and XU
Reimbursement Policy NDRP-GC-005: Modifiers 54 and 55