Transcript California Medical Bill Reviewer Certification

California Medical Bill Reviewer
Certification
Unit 2: Official Medical
Fee Schedule
Module 5: Surgery
©2013 Coventry Health Care. All rights reserved
Proprietary – Do not copy, distribute or disclose without permission of Coventry Health
Overview
Part I: Surgery
 Surgery Guidelines
 Procedures:






Multiple Procedures
Separate Procedures
By Report Procedures
Unlisted Procedures
Microsurgery Procedures
Spinal Fusion Exploration
CA Regulations Training - Surgery
InThen,
the
first
in the
part
second
of this
Hi!
In this
module,
you
Lastly,
you
will learn
part
module,
of this
you
module,
willsurgical
learn
you
will
learn
about
about
Let’sthe
begin
different
by
services,
will learn
abouthow
how
general
they
surgical
are
discussing
modifiers
that
general
are
reimbursed,
andhow
the
assistants,
guidelines,
co-surgeons,
and
surgery
commonly
guidelines...
found
circumstances
that on
can
different
and microsurgeries
procedures
are
are
surgical
bills.
affectreimbursed.
reimbursement.
reimbursed
differently.
What is Surgery?

Surgery is defined as the branch of medicine dealing with
manual and operative procedures for correction of deformities and
defects, repair of injuries, as well as diagnosis and cure of certain
diseases.
In the OMFS, the
surgery section
ranges from 1004069979.
CA Regulations Training - Surgery
Surgery Guidelines
California has one of the most outdated fee schedules in
the country.
 In some cases, this
requires the use of
older versions of the
CPT and other
references to clarify
guidelines pertaining to
This is apparent in the surgical
old codes.
section because:
 There are also rules
 New codes for current procedures
and guidelines unique
have not been added.
to California’s surgery
 Old codes are still in place which
section which you may
have been deleted from the CPT.
not see in other states.

CA Regulations Training - Surgery
Surgery Guidelines

For example, many states
simply allow an E & M
service on the day of
surgery if Modifier 57 is
attached, which designates
this service as a decision
for surgery.

CA Regulations Training - Surgery
However, California also further
stipulates that prolonged
detention or evaluation is required
to determine the need for surgery.
Surgical Evaluation
Prolonged Evaluation
Required
Prolonged Evaluation
Not Required
If an injured worker is admitted
for a head injury and has to be
observed to determine if there is
intracranial bleeding, prolonged
evaluation is required.
On the other hand, if an injured
worker is admitted with an open
fracture of the wrist prolonged
evaluation or detention is not
necessary, as it is obvious
surgical intervention is needed.
CA Regulations Training - Surgery
Surgical Consultation

A valid consultation is also allowable the day of surgery, but it
must qualify as a true consultation.
“Hi...I have a patient here
with an open wrist
fracture...”
A consultation is
only allowable if...
...the physician is
called in to give an
opinion, not to take
over care.
CA Regulations Training - Surgery
For example, if an orthopedic
surgeon is called in by the ER
physician to care for that
open fracture of the wrist, he
is not called to give an
opinion--he is called to take
over care of the patient.
Multiple
Procedures
Part I: Surgery
 Surgery Guidelines
 Procedures:






Multiple Procedures
Separate Procedures
By Report Procedures
Unlisted Procedures
Microsurgery Procedures
Spinal Fusion Exploration
CA Regulations Training - Surgery
Now that you
understand some basics
of surgical
guidelines,
Let’s
start by
learning
let’s discuss how multiple
how multiple
procedures, separate
procedures
procedures,
by are
report
cascaded...
procedures,
and unlisted
procedures are
reimbursed.
Multiple Procedures

California is one of the few states with a multiple cascade
rule for multiple surgical procedures that cascades beyond 50%
reimbursement.
A multiple cascade rule allows
full reimbursement of the
procedure with the highest value,
and reduces the subsequent
procedures by a percentage of the
total fee schedule allowance.
There are also a handful of minor
arthroscopic procedures which only pay
10% of their fee schedule value when
billed with other arthroscopic procedures
on the same joint.
CA Regulations Training - Surgery
Procedures that are
reimbursed per a multiple
cascade are reimbursed at
100%, 50%, and 25%,
respectively.
Multiple Procedures


Multiple procedure values are
built into the system and only
need special attention when
manual pricing is required.
It is important to remember
the percentages are applied
only to allowable charges
and in the order of value,
from highest to lowest.
CA Regulations Training - Surgery
Multiple Procedure
Example
If five charges are billed and one
is denied as an incidental
procedure, the cascade is only
applied to the remaining four
procedures.
As you learned, the highest paid
procedure is reimbursed at
100% of fee schedule value, the
second is paid at 50%, and the
remaining two charges are paid
at 25% of fee schedule value.
Multiple Procedures

There are exceptions to multiple cascade rules.
These exceptions include
the:


“each additional” code
“add-on” code
These codes are already
discounted and are reimbursed
at 100% of their fee schedule
values.
CA Regulations Training - Surgery
These codes are clearly
marked in the fee
schedule and are
excluded from multiple
cutback in the system.
Multiple
Procedures
Part I: Surgery
 Surgery Guidelines
 Procedures:






Multiple Procedures
Separate Procedures
By Report Procedures
Unlisted Procedures
Microsurgery Procedures
Spinal Fusion Exploration
CA Regulations Training - Surgery
Now that you are
familiar with multiple
procedures, let’s take a
look at how separate
procedures are
reimbursed.
Separate Procedures

Like multiple procedures, there are reimbursement
guidelines for those procedures that are unrelated to other
services performed, known as separate procedures.
The separate procedure designation in California is the same as
CPT, but is widely misunderstood by providers and payors alike.
Recall that separate
procedures are independent of,
and not immediately related to,
other services performed, for which
reimbursement is ALLOWED.
CA Regulations Training - Surgery
Put another way, a
separate procedure is
only payable if it is billed
alone, or with an
unrelated service.
Separate Procedures

The separate procedure rule denies reimbursement
for procedures that are related.
The separate procedure rule
typically applies to:



Separate procedures that are
performed in the same joint or body
area as the primary service.
Injections of supplemental
medications into the same catheter.
A manipulation or diagnostic service
before the primary procedure.
CA Regulations Training - Surgery
By Report
Procedures
Part I: Surgery
 Surgery Guidelines
 Procedures:






Multiple Procedures
Separate Procedures
By Report Procedures
Unlisted Procedures
Microsurgery Procedures
Spinal Fusion Exploration
CA Regulations Training - Surgery
Now let’s compare how
By Report and unlisted
procedures are
reimbursed...
By Report Procedures

Unlike other procedure codes, some codes are variable or
unusual enough to not have a standard value.
These codes are listed as By
Report.
By report codes need to be
evaluated along with a
procedural report to see what
specific procedure is similar
enough in time and
complexity to give a value to
be paid.
CA Regulations Training - Surgery
By Report Procedures

For example, CPT 12007, which is listed as a by
report procedure, codes for a simple wound repair
over 30 cm.
This could be evaluated by reading the report and
assessing whether the total simple repair length was
as little as 35 cm or as great as 60 cm.
If the report indicated a
repair of 35 cm, the
But if the report
value of the 20.1 cmindicated a 60 cm repair,
30.0 cm repair code (CPT
the value could be
12006) could be
increased by 50%.
increased by 25%.
CA Regulations Training - Surgery
By Report Procedures

Similarly, CPT 15878, which codes for suction-assisted lipectomy
of the upper extremity, is a By Report procedure.
The value of this procedure
must be determined by reading
the report, and comparing it to
a case of similar complexity,
such as CPT 15836: Excision
of excessive skin and
subcutaneous tissue (including
lipectomy); arm.
CA Regulations Training - Surgery
By Report Procedures
If you are not comfortable in
making this comparison, the
supervisor or a medical
colleague can assist in the
pricing. It is not necessary to
allow the payment in full.
CA Regulations Training - Surgery
Unlisted Procedures

Unlisted procedures require much the same handling as By
Report procedures.

However, unlisted procedures
require an additional step to
identify which specific service
is being billed as unlisted.

CA Regulations Training - Surgery
This is a common occurrence in
surgery because new procedures are
always being introduced and better
instrumentation and techniques are
developed.
Unlisted Procedures
For instance, in the 1980s and
1990s, the intraocular lens
replacements for cataracts
changed tremendously.
Then arthroscopic procedures
for joints were introduced, and
now disc replacement surgery
in the spinal column is
becoming common.
CA Regulations Training - Surgery
As you know,
when new
procedures are
developed, it
takes time for
coding and
pricing to catch
up. This is a
valid use of
unlisted
procedure
codes.
Unlisted Procedures

However, there are also minor changes in technique and
instrumentation that do not change the essential nature of the
procedure.
These minor changes do not
require new coding. Therefore,
using unlisted codes for these is
unnecessary.

If a laser knife is used instead
of a scalpel, it is still an
excision.
CA Regulations Training - Surgery
Review of documentation is
critical to finding out exactly
what service was performed
and whether the use of an
unlisted procedure code is
justified.
Special Procedures
There are special types
of procedures, such as
microsurgery and
spinal fusion
exploration that are
reimbursed differently
in California than other
states.
CA Regulations Training - Surgery
Microsurgery

Microsurgery, which requires the use of magnification and
extreme precision, is reimbursed differently in California than
other states.
California has not yet adopted
the CPT microsurgery code
69990 and its instructions
used in most states.
Instead, microscope use is
billed with CPT 61712 and
is payable for intracranial
and intradural procedures
only.
CA Regulations Training - Surgery
Microsurgery

This eliminates most spinal surgeries like diskectomies and
fusions because these procedures are extradural, which means
the surgeon carefully stays outside the dural sac surrounding the
spinal cord.

The system is programmed to
deny CPT 61712 if billed
with non-qualifying codes.

CA Regulations Training - Surgery
No
Reimbursement
Use of loupes, or magnifying
eyeglasses, does not qualify for
microsurgery reimbursement.
Microsurgery

So, what microsurgery procedures are payable?
CPT 61712 is payable for
microscope use during
intradural spinal surgery &
intracranial surgery. The
provider is reimbursed 25% of
the primary procedure.
CPT 64830 is payable for
microscope use with nerve
dissection or repair and is
reimbursed 50% of the
primary procedure.
CA Regulations Training - Surgery
Modifier –20
Modifier 20 is
is used when a
informational
microsurgery
only and does
requires a
not add to the
surgical
reimbursement.
microscope.
Exploration of Spinal Fusion


In contrast to Medicare and all other states, California allows
CPT 22830: spinal fusion exploration to be billed with other
spinal surgeries.
Every other reference considers
exploration of the operative
In fact, physicians have been
field to be a basic service
successfully sued for not
rendered as part of the primary
exploring the operative area
service.
and identifying a cancer or
other potential problem that
could have been recognized
and treated if only it had
been recognized in time.
CA Regulations Training - Surgery
Exploration of Spinal Fusion

But the California OMFS states: “Exploration of spinal fusion, CPT
22830, is not incidental to other surgical spine procedures and is
separately reimbursable.”
The system is set up to allow this
charge when billed with other
spinal surgeries.
Do not manually deny this
code as included in other
services.
CA Regulations Training - Surgery
Surgical
Reimbursements
Many different people
contribute to a single
Let’s
start by
discussing
surgical
procedure.
how surgical
assistants
Therefore,
reimbursement
are
reimbursed depends
for their
on who
performs or
services...
assists with the
procedure.
Part II: Who Performs Surgery?


Surgical Assistants
Co-Surgeons
CA Regulations Training - Surgery
Surgical Assistants

As you know, there is often an assistant present on a
surgical case.
Two issues are key to surgical
assisting:


CA Regulations Training - Surgery
Who assists the surgeon?
Is the assistance necessary?
Surgical Assistants

California specifically limits surgical assisting to two different types
of providers:
Physicians
CA Regulations Training - Surgery
Licensed non-physician
health care providers
Surgical Assistants

Physicians can used several different types of modifiers to bill for
their services.
Modifier 80 & 82
Modifier 81
Physicians who render
assistant care use
modifiers 80 or 82 and
are reimbursed 20% of
the fee schedule
allowance for each
surgical procedure.
Physicians who render
minimal assistance—
the assistant arrives
late, leaves early, or
both—use modifier 81
and reimbursed 1.1
surgical units,
regardless of the
procedure performed.
CA Regulations Training - Surgery
Surgical Assistants

The non-physician assistant group consists of three different
types of providers who are licensed by the State.
Non-physician
assistants include:



Registered Nurses
RN First Assistants
(RNFAs)
Physician Assistants



In contrast...
Operating Room Technicians
Certified Operating Room
Technicians
Office Assistants
...are not licensed by the
State, and do not qualify
for reimbursement if
assisting in surgery.
CA Regulations Training - Surgery
Surgical Assistants


California’s Official Medical
Fee Schedule does not
designate which procedures
are allowable for assistant
reimbursement.
CA Regulations Training - Surgery
Our system utilizes the eligibility
criteria set out by Medicare to
deny assistant charges for
certain minor surgical
procedures. This is accepted by
the State and the provider
community.
Surgical Assistants

Some surgical procedures do not require an assistant.

The scrub nurse can provide sufficient assistance on minor
services such as injections and manipulations, as well as certain
small-field surgeries such as hands or ears.
For example, common hand
procedures can be adequately
accomplished with a scrub
nurse who retracts adjacent
tissue, keeps the operative field
dry, cuts suture, and performs
other assistance as needed.
CA Regulations Training - Surgery
Co-Surgeons
Sometimes, two
surgeons perform a
single surgical
procedure.
CA Regulations Training - Surgery
Co-Surgeons

In some instances, the skills of two surgeons are
required to perform a single surgical procedure.
When the skills of two surgeons
are required and they choose to
work as equals rather than as a
surgeon and assistant, they are
designated co-surgeons.
CA Regulations Training - Surgery
Co-Surgeon Reimbursement

The reimbursement for two co-surgeons is calculated
by the bill review system.
The modifier 62 is attached to billed
charges on each surgeon’s bill and the
payment is increased by 25%, then split
evenly between the co-surgeons unless
they request a specific percentage split.
Co-Surgeon Reimbursement
(100% x Total Reimbursement) + (25% x Total Reimbursement) = 125% /2 = 62.5%
CA Regulations Training - Surgery
Co-Surgeon Reimbursement

Don’t forget that procedures performed by co-surgeons may be
subject to both multiple cascade and co-surgeon reductions.
Suppose two surgeons perform two procedures on the same patient.
Procedure 1:
Total Value = $1500.00
Procedure 2:
Total Value = $500.00
$1500 x 0.625 = $937.50
$500 x 0.625 x 0.50 = $156.25
Co-Surgeon Reimbursement
$937.50 + $156.25 = 1093.75/2 = 546.88 each
CA Regulations Training - Surgery
Co-Surgeons

If co-surgeons send in their bills separately and the first charges
as surgeon and the second as co-surgeon, the system will not
process the reimbursement.

In order for reimbursement to
occur, one of two options
must occur.
CA Regulations Training - Surgery
Let’s take a look…
Co-Surgeons
Option 1
1. The first surgeon must
agree to change his
designation to co-surgeon.
2. Take a reduction in
payment and refund the
additional funds paid.
CA Regulations Training - Surgery
Option 2
1. The first surgeon remains
designated as surgeon.
2. The second surgeon’s
charges have to be listed as
assistant fees.
Co-Surgeons
Remember, check the report
for more information!
The operative report may
help clarify the issue or a
phone call to the provider
may be required.
CA Regulations Training - Surgery
Now that you
understand
how
different
Let’s start by
discussing
of surgical
howtypes
modifiers
are used
procedures are
to indicate
reimbursed,
let’s atake a
significantly
difficult
look at the different
procedure
onproviders
a bill...
modifiers
that
may use on surgical bills.
Modifiers
Part III: Modifiers





Modifier
Modifier
Modifier
Modifier
Modifier
CA Regulations Training - Surgery
–22
–25
–50
–51
–59
Modifiers

As you know, modifiers attached to a billed charge are used
to signify additional information for processing the charge.
For instance, as you learned
earlier, Modifier 80 tells us the
bill is for the assistant and should
be paid at 20% of the fee
schedule allowance.

As you just learned, some
modifiers, liked Modifier 20, are
informational and do not affect
pricing at all.
In addition to the modifiers that you have already learned about,
there are several other commonly used modifiers on California
surgery bills.
CA Regulations Training - Surgery
Modifier 22

Modifier 22 indicates that a procedure was more difficult than
normal.
22 Unusual procedural services:
This modifier is used to indicate a
procedure was more difficult due to
unusual anatomy, excessive bleeding,
extensive scarring, or any other
problem that requires considerable
additional time or skill.
CA Regulations Training - Surgery
Modifier 22

There is a normal range of difficulty for any procedure due
to differences in personal anatomy.
The provider is not paid less if the
procedure is unusually easy, nor should
he expect to be paid extra if the
procedure is slightly more difficult than
usual.

CA Regulations Training - Surgery
Outside that normal range, though, a
surgeon may request additional
consideration for an unusually difficult
case.
Modifier 22

Example 1
Example 2
Back surgery performed on a
500-pound man could be
unusually difficult due to the
positioning and depth of the
incision required.
A patient with bleeding problems
could take much longer on the
operating table than usual to
make sure bleeding is controlled.
The reimbursement for documented 22 usage is an additional 25% and
is not necessarily applicable to the whole bill, but only to the difficult
procedure specifically.
CA Regulations Training - Surgery
Modifier 25

Modifier 25 is used to indicate a separate E & M service
provided on the same day as surgery.
25 Significant, separately
identifiable E/M service on same
day as surgery

The key is documentation and
pattern of visits.
CA Regulations Training - Surgery
Modifier 25
Example 1
Example 2
If the procedure was scheduled
in advance and only routine
discussion of the procedural facts
took place, the E/M visit is not a
significant other service.
If, at the time of a procedure,
the next visit and procedure are
scheduled and the questions are
routine regarding the patient, his
pain, or the procedure, the E/M
visit is not justified whether or
not a 25 is attached.
Example 3
In contrast, if a provider
discusses other conditions or
problems with the patient,
adjusts medications, or counsels
them, the 25 is payable and the
E/M visit can be allowed.
CA Regulations Training - Surgery
For example, weekly pain
injections with an
accompanying E/M charge,
billed with Modifier 25, should
be questioned.
Modifier 47

You might remember from studying anesthesia that Modifier 47
is used to indicate that regional or general anesthesia was
administered by a surgeon.
47 Anesthesia by Surgeon:
Regional anesthesia provided by a
surgeon.
The surgeon is paid the base
value of the anesthesia service
without time units (the 1 required
in the unit field is subtracted by
the system). This is not
applicable with local infiltration,
digital block, topical application,
or IV sedation.
CA Regulations Training - Surgery
Modifier 50


Modifier 50 is used to indicate that a bilateral procedure was
performed.
This prevents an automatic
cutback for multiple
procedures and an
additional cutback for
bilateral procedures.
CA Regulations Training - Surgery
50 Bilateral Procedures:
Since the guidelines instruct to
cascade bilateral procedures the
same as multiple procedures, these
cutbacks are all programmed into
the system, and attaching the 50 is
informational only.
Modifier 50

Surgical procedures cascade from 100% to 50% to 25% whether
they are unilateral or bilateral.
Suppose three procedures are billed.
Two procedures are bilateral and
valued higher than the third
service.
The first side would pay at
100%, the second
side at 50%, and
the final
procedure at
25%, respectively.
CA Regulations Training - Surgery
Two procedures are bilateral and
valued less than the third service.
The third service would pay at
100%, and the bilateral
procedures would pay
50% and 25%,
respectively.
Modifier 51

As you know, any surgical code, even injections, not designated
as “add-on” or “each additional” is subject to reductions.

Multiple procedures are
indicated by Modifier 51.
CA Regulations Training - Surgery
51 Multiple Procedures:
Multiple procedures are subject
to the cascade rule, which
reimburses the highest value
procedure at 100%, and the
subsequent procedures at 50%
and 25%, respectively.
Modifier 51

There are a few things that you should remember
when reviewing bills with multiple procedures.
Multiple Procedures
The primary procedure
is not determined by
billed charge, but by
fee schedule value.
The highest billed
charge does not
always correspond to
the highest value.
CA Regulations Training - Surgery
Body area change does
not start the multiple
cascade over. If the
procedures are in the
same operative session,
they are subject to
multiple cascade.
Modifier 59

Sometimes a modifier is necessary to indicate a distinct
procedure performed in conjunction with another procedure,
normally part of the same primary service.

In these instances, Modifier
59 is used.
CA Regulations Training - Surgery
59 Distinct Procedural
Service:
Used when a code normally
included as part of a primary
service is distinct enough to be
considered a separate
procedure.
Modifier 59

There must be a justifiable reason that a procedure normally
included in the primary service, within the same surgery, is
not included, and is considered a separate procedure.
Modifier 59 is NOT the magic
pill to get a code paid.
Merely placing this
modifier on a billed code
does not automatically
qualify it for payment.
CA Regulations Training - Surgery
Modifier 59
Example:
Non-Reimbursable
Example:
Reimbursable
1. A diagnostic shoulder
arthroscopy that is billed
with a therapeutic arthroscopic
procedure would normally not be
reimbursable because they are
both part of the same primary
service.
2. An injection code billed with a
knee tendon repair would be
included in the global surgical
package, and therefore is not
reimbursable.
1. However, if the diagnostic
arthroscopy was performed in
the opposite shoulder, 59 should
be attached to the billed code
and it should be paid, because
the procedures are distinct and
separate.
CA Regulations Training - Surgery
2. But if the injection were in the
other knee or a shoulder joint, it
would be eligible for 59 and
reimbursement.
Modifier 59
Providers who
misunderstand how
to apply Modifier 59
place it on otherwise
non-payable codes
in the hope that it
will pass through the
system and be paid.
CA Regulations Training - Surgery
The processor
must be aware that
Modifier 59 is
considered by the
Federal Office of the
Inspector General to
be the most abused
modifier in medical
billing.
That’s right!
What is the best way to
Documentation
that supports
confirm if Modifier –59 is
modifier
mustcorrectly?
be present in
being59
billed
order to receive payment.
Summary
Surgery: Guidelines,
Evaluation, &
Consultation
How microsurgery and
spinal fusion
exploration procedures
are reimbursed.
How multiple and
separate procedures
are reimbursed.
Reimbursement:
Surgical Assistants &
Co-Surgeons
How By Report and
Unlisted procedures
are reimbursed.
Modifiers: How
common modifiers
affect reimbursement.
CA Regulations Training - Surgery
Module Quiz
It’s time to check your knowledge of the concepts presented in this
module.

This quiz is scored.

You must achieve a score of 80% to pass. You may attempt this
quiz as many times as needed to achieve a passing score.

When finished, you may move on to the next module.
CA Regulations Training - Surgery
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