Global Period Modifiers: How Do They Impact Reimbursement?

Transcription

1 Global Period Modifiers: How Do They Impact Reimbursement? September 1, 2016 What reimbursement should we expect when using the global period modifiers 58, 79 and 78? Global period modifiers are used to indicate that a subsequent procedure was performed during the global period of a prior procedure. Modifiers alert the payer of your rationale for allowing payment for the subsequent procedure. The modifiers and reimbursement impact of each is shown below: Modifier 58: Indicates that a subsequent procedure was performed as a (1) planned or anticipated (staged); (2) more extensive than the original procedure; or (3) for therapy following a surgical procedure. Reimbursement should be 100% of the allowable and the global period is extended to that of the subsequent procedure. Modifier 79: Is appended to CPT code to show that an unrelated procedure was performed during the global period of a prior procedure. Again, reimbursement should be at 100% of the allowable and you re now in a separate global period that is related to the subsequent procedure. Modifiers 78: Indicates that an unplanned, related procedure was performed in the operating room, catheterization or endoscopy suite. Typically this is treatment of a complication such as wound dehiscence, infection, etc. Reimbursement is typically at 70-80% of the allowable. Why? The reduction accounts for overlapping pre- and post-op care which was paid under the original procedure. Therefore, the payment for modifier 78 is for only the intra- operative portion of the

2 unplanned, related procedure. of 09/01/16. New Patients and PAs September 1, 2016 Our office-based PA usually sees established patients with established problems, and the supervising physician is onsite. What should we do if the PA sees a new patient or a returning patient has a new problem? The practice has two options. First, the PA could simply bill that visit using the direct method (under the PA s name). Alternately, a physician could see the new patient to set the plan of care, with the visit reported by the physician. Remember, for a new patient or new problem seen in the office setting, the physician cannot use the documentation elements already captured by the PA; code assignment would be based only on the work the physician performs and documents. of 09/01/16.

3 Reimbursement: Assistant Surgeon What is the reimbursement for an assistant surgeon using modifier 80? Is the payment different for the primary and the assistant? Assistant surgeon is described as one surgeon, of the same or a different specialty, providing assistance during a surgical procedure or CPT code. Modifier 80 (modifier 82 for an assistant surgeon in an academic setting when a qualified resident is not available) is appended to any CPT code the assistant participates in. Medicare reimburses 16% of the allowable for the assistant surgeon (modifier 80 or 82) and multiple procedure/bilateral procedure reductions also apply. The primary surgeon s fee is not affected. In an assistant surgeon scenario, the assistant need not and should not dictate a separate note. However, it is critical that the primary surgeon document in his/her note, specifically what the assistant did. Stating an assistant was needed because the case was complex is not sufficient. The primary surgeon must state what the assistant did, for example, assisting with the resection, anastomosis, etc. For private payers, coding guidelines and payment may vary.

4 Excision of Scar Patient comes in for what they are calling scar revision and the note states that standing cutaneous excess of the left abdominal scar was sharply excised. We are billing with a diagnosis of hypertrophic scar (L91.0) and CPT codes of (excision of benign lesion) and (intermediate repair) for the procedure. On speaking with a co-worker regarding the note, since I m new to plastics surgery, we are wondering if we should bill with 52 modifier because it appears to me that the excess skin is being removed. What do you think? CPT says for scar revision to use a complex repair code such as Do not use the benign lesion removal and intermediate repair code combination (11404 and 12034). Also, do not use that code says Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy. CPT is meant for procedures commonly referred to as a panniculectomy to prevent the occurrence of recurring rashes, skin maceration, and yeast infections that develop in the abdominopelvic fold following extreme weight loss not for scar revision.

5 Surgical Modifiers: How Do They Impact Reimbursement? What reimbursement should we expect when using the global period modifiers 58, 79 and 78? Surgical modifiers are used to indicate that a subsequent procedure was performed during the global period of a prior surgery. Modifiers tell the payer the rationale for allowing payment for this subsequent procedure. The modifiers and reimbursement impact of each is shown below: Modifier 58: to indicate a second procedure was performed as a staged procedure. Reimbursement should be 100% of the allowable fee. Modifier 79: To indicate an unrelated procedure was performed during the global period of the original procedure. Reimbursement should be 100% of the allowable fee. Modifiers 78: To indicate that a complication of an original procedure was treated by a return to the operating room, catheterization or endoscopy suite. Reimbursement should be at 70-80% of the allowable fee. This reduction reimburses for the intra-operative portion of the procedure only, since the patients pre and post-operative services are paid under the original surgery s flat fee.

6 Look for an upcoming KZA Webinar on Modifiers for surgeons: What you need to know, which will cover modifiers 22, 59, 58, 79 and 78. Also stay tuned for another KZA webinar Surgeon Role Modifiers. Co-surgeon, assistant Surgeon, or coding separate codes: current coding and documentation Guidelines. Reimbursement: Co-surgery What is the reimbursement for co-surgery? Is it different for the primary and co-surgeon? For Medicare, co-surgery requires two different specialties performing separate parts of a single CPT code. For both surgeons, a 62 modifier is appended to the appropriate CPT code(s). Medicare multiples the allowable fee by 125% and splits the reimbursement exactly in half, resulting in a payment of 62.5% to each surgeon. Both surgeons dictate an operative note describing their work and both have postoperative responsibilities.

7 Is It Co-Surgery or Not? I was called into the OR by a urologist who was doing a nephrectomy for a malignancy. He noted a lesion on the spleen I was called in to remove the spleen. Is this co-surgery or assistant surgery? Thank you for your question. In the American College of Surgeons (ACS) coding course, we discuss numerous scenarios where more than one surgeon participates in a surgery. Cosurgery and assistant surgery have specific criteria and documentation requirements. In the scenario you describe, the urologist will report the appropriate nephrectomy code. The CPT codes for a nephrectomy for malignancy are not described or valued to include a splenectomy. Therefore this is not cosurgery or assistant surgery. You will code for the splenectomy only. Please join us in Dallas or Chicago for upcoming ACS coding courses.

8 Anterior-Posterior Spine Surgery Bone Grafts I did an anterior and posterior spine procedure on the same day. I used local bone graft (20936) and morselized allograft (20930) on the anterior and posterior procedures. Should I bill 20930, , 20936, or x 2 units with x 2 units? Actually, neither. CPT guidelines say to bill the applicable bone graft code(s) only once per operative session. Signing NPP Notes Do I have to sign each of my NP s notes that are reported incident to? The guidelines for reviewing and signing NPP documentation are set by each state in its scope of practice regulations. Each practice must research those requirements individually. But as

9 an employer, you are responsible for the care provided by the NP, and reviewing and signing off on the notes may be an efficient method for keeping tabs on patient treatment. Orthopedic Spine Coding We have a billing company for which we bill for many different specialties. We have an orthopedic spine doctor who insists we bill the cage code for each inter-space. However, the CPT book lists as cage(s) therefore our thinking is that no matter how many are placed this code is only allowed one time per surgery. His note states C3-C4, C4-C5, C5-C6 anterior cervical interbody fusion using PEEK titanium interbody spacers. Your client is correct. CPT code is reported per interspace to describe intervertebral biomechanical devices, including PEEK cages. The term is both, single or plural, cage(s), because sometimes there are two devices placed at a single spinal level. If you do an internet search on PEEK cages, you ll find a variety of designs. As long as the supporting documentation in the body of the note is appropriate, the statement above supports 3 units of Remember that this CPT code is not subject to multiple procedure discounts.

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