Global Surgical Periods to Change for the CSHCN Services Program

Transcription

1 Glbal Surgical Perids t Change fr the CSHCN Services Prgram Infrmatin psted March 5, 2010 Effective fr dates f service n r after May 1, 2010, the glbal surgical perid and the usage f certain mdifiers will change fr the Children with Special Health Care Needs (CSHCN) Services Prgram. Prviders wh perfrm surgical prcedures befre May 1, 2010, must cntinue t bill services using the current prcess. The fllwing changes will apply t surgical prcedures that are perfrmed n r after May 1, The CSHCN Services Prgram uses glbal surgical perids t determine reimbursement fr surgical prcedures. The fllwing services are included in the glbal surgical perid: Preperative care, including histry and physical Hspital admissin wrk-up Anesthesia (when administered and mnitred by the primary surgen) Surgical prcedure (intraperative) Pstperative fllw-up and related services Cmplicatins fllwing the surgical prcedure that d nt require return trips t the perating rm The CSHCN Services Prgram will adhere t a glbal fee cncept fr minr and majr surgeries and invasive diagnstic prcedures. Glbal surgical perids are defined as fllws: 0-day Glbal Perid Reimbursement includes the surgical prcedure and all assciated services that are prvided n the same day. 10-day Glbal Perid Reimbursement includes the surgical prcedure and all assciated services prvided n the day f the surgery and thrugh 10 days after the surgical prcedure. 90-day Glbal Perid Reimbursement includes the surgical prcedure, preperative services that are prvided n the day befre the surgical prcedure, all assciated services that are prvided n the day f the surgery and thrugh 90 days after the surgical prcedure. Prcedure cdes that are designated as "Carrier Discretin" will have their glbal perids determined by the CSHCN Services Prgram. Mdifiers T align with the Centers fr Medicare & Medicaid Services (CMS), the CSHCN Services Prgram will add certain mdifiers that are related t surgical services. Fr services that are rendered in the preperative, intraperative, r pstperative perid t be crrectly reimbursed, prviders must use the apprpriate mdifiers frm the fllwing table. Failure t use the apprpriate mdifier may result in recupment.

2 Mdifiers If a physician prvided all f the preperative, intraperative, and pstperative care, claims may be cnsidered fr reimbursement when they are submitted withut a mdifier. Dcumentatin Requirements Fr services that are billed with any f the listed mdifiers t be cnsidered fr reimbursement, prviders must maintain in the client s medical recrd dcumentatin that supprts the medical necessity f the services. Acceptable dcumentatin includes, but is nt limited t, prgress ntes, perative reprts, labratry reprts, and hspital recrds. On a case-by-case basis, prviders may be required t submit additinal dcumentatin that supprts the medical necessity f services befre the claim will be reimbursed. Nte: Retrspective review may be perfrmed t ensure that the submitted dcumentatin supprts the medical necessity f the surgical prcedure and any mdifier used t bill the claim. Prir Authrizatin There are n changes t prir authrizatin requirements. Prviders can refer t the 2009 CSHCN Services Prgram Prvider Manual fr additinal infrmatin abut surgical prcedures. Reimbursement The glbal surgical fee perid will apply t bth emergency and nnemergency surgical prcedures. Physicians wh are in the same grup practice and specialty must bill, and will be reimbursed, as if they were a single prvider. Evaluatin and Management (E/M) Services E/M services that are rendered n the day f the surgical prcedure r service are generally nt payable fr prcedures that have a 0-day glbal perid. E/M services that are rendered n the day f the surgical prcedure r service r during the 10-day pstperative perid are generally nt payable fr prcedures that have a 10- day glbal perid. E/M services that are rendered n the day befre the surgical prcedure r service, n the day f the surgical prcedure r service, r during the 90-day pstperative perid are generally nt payable fr prcedures that have a 90-day glbal perid. Radilgy and labratry services related t the surgical prcedure are nt subject t the glbal perid and are reimbursed separately.

3 Preperative Services Preperative physician E/M services (such as ffice r hspital visits) that are prvided during the preperative limitatin perid and are directly related t the planned surgical prcedure will be denied if they are billed by the surgen r anesthesilgist wh was invlved in the surgical prcedure. Reimbursement will be cnsidered when the E/M services are perfrmed fr distinct reasns that are unrelated t the prcedure. E/M services that meet the definitin f a significant, separately identifiable service may be billed with mdifier 25 if they are prvided n the same day by the same prvider as the surgical prcedure. Mdifier 25 is nt used t reprt an E/M service that results in a decisin t perfrm a surgical prcedure. Medical recrd dcumentatin must substantiate the use f mdifier 25. If the decisin t perfrm a minr prcedure is made during an E/M visit immediately befre the surgical prcedure, the E/M visit is cnsidered a rutine preperative service and is nt separately billable. Physicians wh prvide nly preperative services fr surgical prcedures with a 10- r 90-day glbal perid may submit claims using the surgical prcedure cde with the identifying mdifier 56. Reimbursement will be limited t a percentage f the fee fr the surgical prcedure. E/M services that are prvided during the preperative perid (ne day befre r the same day) f a majr surgical prcedure (90-day glbal perid) and result in the initial decisin t perfrm the surgical prcedure may be cnsidered fr reimbursement when they are billed with mdifier 57. The client s medical recrd shuld clearly indicate when the initial decisin t perfrm the prcedure was made. Intraperative Services Physicians wh perfrmed a surgical prcedure with a 10- r 90-day glbal perid but d nt render pstperative services must bill the surgical prcedure cde with the mdifier 54. Mdifier 54 indicates that the surgen is relinquishing all the pstperative care t a physician utside f the same grup. Dcumentatin in the medical recrd must supprt the transfer f care and must indicate that an agreement has been made with anther physician t prvide the pstperative management. The CSHCN Services Prgram reimburses csurgens fr surgical prcedures that are billed with mdifier 62 if the Texas Medicaid fee schedule indicates that the prcedure allws fr csurgens. Claims will be suspended fr manual review f the dcumentatin f medical necessity. Reimbursement will be calculated at 62.5 percent f the amunt allwed fr the intraperative prtin f the surgical prcedure s fee. Pstperative services Pstperative services that are directly related t the surgical prcedure are included in the glbal surgical fee and are nt reimbursed separately. Pstperative services include, but are nt limited t, all f the fllwing: Fllw-up visits (any place f service) Pain management

4 Miscellaneus services, including: Dressing changes Lcal incisin care Platelet gel Remval f perative packs Remval f cutaneus sutures, staples, lines, wires, drains, casts, r splints Replacement f vascular access lines Insertin, irrigatin, and remval f urinary catheters, rutine peripheral intravenus lines, nasgastric tubes, and rectal tubes Changes r remval f trachestmy tubes Nte: Remval f pstperative dressings r anesthetic devices is nt eligible fr separate reimbursement as the remval is cnsidered part f the allwance fr the primary surgical prcedure. Staged r related surgical prcedures r services that are perfrmed during the pstperative perid may be reimbursed when they are billed with mdifier 58. A pstperative perid will be assigned t the subsequent prcedure. Dcumentatin must indicate that the subsequent prcedure r service was nt the result f a cmplicatin r any f the fllwing: It was planned at the time f the initial surgical prcedure. It is mre extensive than the initial surgical prcedure. It is fr therapy fllwing an invasive diagnstic surgical prcedure. Nte: Mdifier 58 des nt apply t prcedure cdes that are already defined as staged r sessined services in the Current Prcedural Terminlgy (CPT) Manual (e.g., r 66821). E/M services that are prvided by the same prvider fr reasns that are unrelated t the perative surgical prcedure may be cnsidered fr reimbursement if they are billed with mdifier 24. The submitted dcumentatin must substantiate the reasns fr prviding E/M services. Mdifier 24 must be billed with mdifier 25 if a significant, separately identifiable E/M service that was perfrmed n the day f a prcedure falls within the pstperative perid f anther unrelated prcedure. The pstperative mdifier shuld always be billed befre any ther mdifiers. Mdifier 24 must be billed with mdifier 57 if an E/M service that was perfrmed within the pstperative perid f anther unrelated prcedure results in the decisin t perfrm majr surgery. Preperative, Intraperative, and Pstperative Perids If the surgen prvides bth the surgery and the pstperative care fr a prcedure that has a 10- r 90-day glbal perid, the surgen must include the fllwing details n the claim frm:

5 The surgical prcedure, date f the surgery, and mdifier 54, which indicates that he r she was the surgen. The surgical prcedure, date f service, and mdifier 55 t dente the pstperative Nte: Prviders must nt submit a claim fr a prcedure until after the client has been seen during a face-t-face fllw-up visit. If the surgen prvides bth the surgery and the preperative care fr a prcedure that has a 10- r 90-day glbal perid, the surgen must include the fllwing details n the claim frm: The surgical prcedure, date f the surgery, and mdifier 54, which indicates that he r she was the surgen. The surgical prcedure, date f service, and mdifier 56 t dente the preperative If the surgen prvides bth the preperative care and the pstperative care fr a prcedure that has a 10- r 90-day glbal perid, the surgen must include the fllwing details n the claim frm: The surgical prcedure, date f service, and mdifier 55 t dente the pstperative The surgical prcedure, date f service, and mdifier 56 t dente the preperative Fr pstperative care that is rendered by physicians ther than the surgen fr prcedures that have a 10- r 90-day glbal perid, the fllwing cnditins apply: When transfer ccurs immediately after surgery, the physician wh assumes inhspital pstperative care must bill subsequent care prcedure cdes 99231, 99232, r Physicians wh prvide pstdischarge care must bill the apprpriate surgical cde with mdifier 55. Reimbursement will be limited t a percentage f the allwable fee fr the surgical prcedure. Dcumentatin in the medical recrd must include all f the fllwing: A cpy f the written transfer agreement. The dates the care was assumed and relinquished. The claim must indicate in the cmments field f the claim frm the dates n which care was assumed and relinquished, and the units field must reflect the ttal number f pstperative care days prvided. Claims that are submitted n the CMS-1500 paper claim frm must include the date f surgery in Blck 14 and the dates n which care was assumed and relinquished in Blck 19. Pstperative care may be billed nly nce by the same prvider. Claims that are submitted by an assistant surgen will nt be cnsidered fr reimbursement under the fllwing cnditins: When billed with mdifier 58.

6 When billed with mdifier 78 as a return trip t the perating rm fr a related prcedure during the pstperative perid. When billed with mdifier 79 as an unrelated prcedure r service by the same prvider during the pstperative perid. Return Trips t the Operating Rm Return trips t the perating rm fr a repeat surgical prcedure may be cnsidered fr reimbursement when billed with mdifiers 76 and 77. Billing with mdifiers 76 and 77 initiates the beginning f a new glbal perid. Medical recrd dcumentatin must supprt the need fr a repeat prcedure. All surgical prcedure cdes with a predefined limitatin (e.g., nce per lifetime, ne every 5 years) must nt be submitted with mdifier 76 r 77. Fr mdifiers 76 and 77, the repeated prcedure must be the same as the initial surgical prcedure. The repeat prcedure shuld be billed with the apprpriate mdifier. The reasn fr the repeat surgical prcedure shuld be entered in the narrative field n the claim frm. Return trips t the perating rm fr surgical prcedures that are related t the initial surgery (i.e., cmplicatins) may be cnsidered fr reimbursement when they are billed with mdifier 78 by the same prvider. When a surgical prcedure has a "000" glbal perid, the full value f the surgical prcedure will be paid since these cdes have n preperative, pstperative, r intraperative values. When an unlisted prcedure is billed because n cde exists t describe the treatment fr the cmplicatins, reimbursement is a maximum f 50 percent f the value f the intraperative services that were riginally perfrmed. Nte: Only the intraperative prtin f the glbal surgical fee fr the subsequent prcedure will be reimbursed. Reimbursement fr the pstperative perid f the first surgical prcedure includes fllw-up services frm bth surgical prcedures, and n additinal pstperative reimbursement is alltted. The glbal perid will be based n the first surgical prcedure. Billing with mdifier 78 des nt begin a new glbal perid. Surgical prcedures that are perfrmed by the same prvider during the pstperative perid may be cnsidered fr reimbursement when they are billed with mdifier 79 fr any f the fllwing: When the same prcedure is perfrmed with a different diagnsis. When the same prcedure is perfrmed n the left and right side f the bdy in different perative sessins and that prcedure is billed with the RT r LT mdifier. When a different prcedure is perfrmed with the same diagnsis. When a different prcedure is perfrmed with a different diagnsis. Billing with Mdifier 79 initiates a new glbal surgical perid.

7 Fr services that are billed with mdifier 54, 55, r 56, medical recrd dcumentatin must be maintained by bth the surgen and the physician wh prvides preperative r pstperative Where a transfer f pstperative care ccurs, the receiving physician cannt bill fr any part f the glbal services until at least ne service has been prvided. The claim must reflect the date f the surgery and the apprpriate mdifiers. The physician wh prvides the pstperative care must als include the date n which care was assumed until it was relinquished. Reimbursement fr claims assciated with mdifiers 54, 55, r 56 is limited t the same ttal amunt as wuld have been paid if nly ne physician prvided all f the care, regardless f the number f physicians wh actually prvide the Unless therwise stated in the CSHCN Services Prgram Prvider Manual, n additinal reimbursement is prvided t physicians wh elect t use special instruments r advanced technlgy t accmplish a surgical prcedure. Surgical prcedures may be reimbursed at the lesser f the billed amunt r the amunt allwed by Texas Medicaid.