Reimbursements

Category:

Repeat Surgical Procedures

Reimbursement Policy:  NDRP-SURG-010   
Topic:  Surgery
Effective Date:  July 1, 2018
Last Reviewed:
March 1, 2019

   


Description:

The purpose of this policy is to provide direction on how the Plan handles “repeated” or “redone” surgical procedures.

Policy:

Repeat surgeries are those surgical procedures that need to be “repeated” or “redone” due to a reoccurrence of symptoms or further complications more than one month after the original operation(s). Repeat procedure(s) do not represent the actual surgical procedure and must be reported in addition to the primary procedure being “redone.” These procedures are reported on the same day and by the same provider.

The sole fact that a procedure has to be repeated sometime after the original surgery does not warrant additional payment above the allowance for the current surgical procedure being reported.

If a code that represents a reoperation (i.e., 33530, 35390, or 35700) is reported in addition to the surgical procedure, the charges shall be combined under the appropriate surgical code(s). For a list of the surgical procedures that are applicable to each of these codes, please refer to the latest CPT® Codebook, as published by the American Medical Association (AMA).

If codes 33530, 35390, or 35700 are independently reported, they are non-covered. A participating or network provider cannot bill the member for the non-covered service. These codes do not represent the actual surgical procedure. The specific code for the surgical procedure must be reported in order for payment to be made.