REIMBURSEMENT GUIDELINES
Oxford will reimburse a CPT or HCPCS code only once during the Defined Treatment or Monitoring Period.
Multiple submissions of the same CPT or HCPCS code by the Same Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional for the same patient during the Defined Treatment Period or Monitoring Period will be denied as part of the global service unless an appropriate modifier is reported. Refer to the Modifiers and Attachments sections of this policy.
Services addressed in the One or More Sessions Policy may also be subject to global surgical package guidelines.
Modifiers
Modifiers offer the physician, hospital, ambulatory surgical center or healthcare professional a way to identify that a service or procedure has been altered in some way. Under appropriate circumstances, modifiers should be used to identify unusual circumstances, staged or related procedures, distinct procedural services or separate anatomical location(s).
Oxford recognizes the following designated modifiers, when appropriately reported, under this reimbursement policy:
Modifier Description
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the left side of the body)
50 Bilateral procedure
52 Reduced services
53 Discontinued procedure
54 Surgical care only
55 Postoperative management only
56 Preoperative management only
79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care
Professional During the Postoperative Period
Pricing or Payment Modifier Fact Sheet
Modifier Submission
The Multi-Carrier System (MCS) used for claims processing requires placement of pricing modifiers in the first modifier position to process claims correctly. Place the modifiers listed below (except modifiers with an *) to the right of the procedure code in Item 24D on the CMS-1500 claim form or for ANSI X12 4010 electronic claims submission use segment 2-370-SV101-3.
Processing delays can occur for claims submitted without the pricing modifier in the first modifier position.
AA Anesthesia service personally performed by anesthesiologist AD Medical supervision by a physician; more than four concurrent anesthesia procedures AS* Assistant at surgery services provided by a Physician Assistant (PA) or Nurse Practitioner (NP) KD** Drug administered through a DME infusion pump QK Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals QW CLIA waived tests QX Certified Registered Nurse Anesthetist (CRNA) service: with medical direction by a physician QY Medical direction of one CRNA by an anesthesiologist QZ CRNA service: without medical direction by a physician TC Technical component 26 Professional component
50* Bilateral Procedure performed at the same session on an anatomical site
53 Discontinued procedure (only when appended to procedure codes 45378, G0105, G0121)
54* The surgeon is billing the surgical care only
55* Indicate a physician, other than the surgeon, is billing for part of the outpatient postoperative care Or: Used by the surgeon when providing only a portion of the post-discharge post-operative care
62* Two surgeons (each in a different specialty) are required to perform a specific procedure
66* Team surgeons
73* Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) procedure prior to the administration of anesthesia
78* Return to an operating room for a related procedure during the postoperative period
80* Assistant at surgery service is provided by a medical doctor (MD)
82* Assistant at surgery service provided by a MD when there is no qualified resident available
* These payment modifiers are not limited to the first position. (If there is another pricing modifier submitted that is required to be in the first modifier field, these modifiers should be in the second, third or fourth modifier position.)
** If multiple pricing or payment modifiers are submitted, the KD modifier should be placed in the first modifier position field.
DEFINITIONS
Same Specialty Physician, Hospital, Ambulatory Surgical Center or other Health Care Professional:
Physicians, Hospitals, Ambulatory Surgical Centers and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification number.
Defined Treatment Period: The timeframe that corresponds with the global fee period assigned to a code on the National Physician Fee Schedule Relative Value File. The global fee period is the number of days during which all necessary services normally furnished by a physician (before, during, and after the procedure) are included in the reimbursement for the procedure performed.
Monitoring Period: The timeframe described within a code’s description.
QUESTIONS AND ANSWERS
1 Q: What happens if the Same Physician, Hospital, Ambulatory Surgical Center or ther Health Care Professional had to discontinue or reduce the first surgery, but was able to complete the surgery the second time within the same Defined Treatment Period?
A: If the first surgical procedure was reported with a modifier 52 or 53, upon submission of a second unmodified global code within the same Defined Treatment Period, the partial reimbursement will be djusted and the global code will be reimbursed.
2 Q: What happens if the Same Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional performs the surgery on one eye then performs the surgery on the other eye two weeks later (within the same Defined Treatment Period)?
A: In this case, it is critical that the anatomic modifiers (LT and/or RT) be used appropriately to indicate the eye upon which the surgery was performed with each submission. The subsequent procedure will be considered for reimbursement when appropriate modifiers are reported.
3 Q: What happens if a different surgeon performs subsequent surgeries in the same Defined Treatment Period?
A: If the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional is reporting with the same Federal Tax Identification number (TIN), subsequent surgeries will be denied within the same Defined Treatment Period. If the physician, hospital, ambulatory surgical center or other health care professional is a different specialty and/or different TIN, subsequent surgeries will be considered for reimbursement.
4 Q: If the Same Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional wants to collect data from an implanted cardioverter-defibrillator device and analyze it once a month for three months, will he/she be reimbursed for all three reports?
A: No. The American Medical Association’s (AMA) coding guidelines for CPT codes 93295 and 93296 state that these codes should only be reported once per 90 days. This implies that the Same Physician Hospital, Ambulatory Surgical Center or Other Health Care Professional will only be reimbursed one time in a 90-day Defined Treatment Period. Additional submissions reported by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional reporting with the same Federal Tax Identification number (TIN) would be denied as part of the global service. Additional submissions reported by a physician or other health care professional with a different specialty and/or TIN will be considered for reimbursement.
5 Q: When does the Defined Treatment or Monitoring Period of a procedure begin and end?
A: The Defined Treatment or Monitoring Period begins the day of the procedure and then 10, 30 or 90 days before the procedure and following the procedure, beginning the first day of the procedure. Example: A procedure having a Defined Treatment or Monitoring Period of 90 days is performed on 10/1. Procedures reported on 10/1 and during the 90-day treatment or monitoring period before and after (7/3 through and including 12/30) are included in the treatment or monitoring period. ATTACHMENTS
One or More Sessions Policy List A list of codes with a defined treatment or monitoring period.
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