| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Physician | | 05/10/2024 | Reimbursement : AmountsTopic #656 Surgical Procedures
Surgical procedures performed by the same physician, for the same member, on the same DOS must be submitted on the same claim form. Surgeries that are billed on separate claim forms are denied.
Certain surgical procedures billed on professional claims (i.e., the 837P transaction or the 1500 Health Insurance Claim Form) may be reimbursed only when performed in an inpatient hospital or an ASC.
Reimbursement for most surgical procedures includes reimbursement for preoperative and postoperative care days. Preoperative and postoperative surgical care includes the preoperative evaluation or consultation, postsurgical E&M services (i.e., hospital visits, office visits), suture, and cast removal.
Although E&M services pertaining to the surgery for DOS during the preoperative and postoperative care days are not covered, an E&M service may be reimbursed if it was provided in response to a different diagnosis.
Co-Surgeons
ForwardHealth reimburses each surgeon at 100 percent of ForwardHealth's usual surgeon rate for the specific procedure they have performed. Attach supporting clinical documentation (such as an operative report) clearly marked "co-surgeon" to each surgeon's paper claim to demonstrate medical necessity.
Surgical Assistance
ForwardHealth reimburses surgical assistance services at 20 percent of the reimbursement rate allowed for the provider type for the surgical procedure. To receive reimbursement for surgical assistance, indicate the surgery procedure code with the appropriate assistant surgeon modifier ("80," "81," "82," or "AS") on the claim.
ForwardHealth will automatically calculate the appropriate reimbursement for assistant surgeon services based on the provider type performing the procedure.
Bilateral Surgeries
Bilateral surgical procedures are paid at 150 percent of the maximum allowable fee for the single service. Indicate modifier "50" (bilateral procedure) and a quantity of 1.0 on the claim.
Multiple Surgeries
Multiple surgical procedures performed by the same physician for the same member during the same surgical session are reimbursed at 100 percent of the maximum allowable fee for the primary procedure, 50 percent for the secondary procedure, 25 percent for the tertiary procedure, and 13 percent for all subsequent procedures. The Medicaid-allowed surgery with the greatest usual and customary charge on the claim is reimbursed as the primary surgical procedure, the next highest is the secondary surgical procedure, etc.
ForwardHealth permits full maximum allowable payments for surgeries that are performed on the same DOS but at different surgical sessions. For example, if a provider performs a sterilization on the same DOS as a delivery, the provider may be reimbursed the full maximum allowable fee for both procedures if performed at different times (and if all of the billing requirements were met for the sterilization).
To obtain full reimbursement, submit a claim for all the surgeries performed on the same DOS that are being billed for the member. Then submit an Adjustment/Reconsideration Request for the allowed claim with additional supporting documentation clarifying that the surgeries were performed in separate surgical sessions.
Note: Most diagnostic and certain vascular injection and radiological procedures are not subject to the multiple surgery reimbursement limits. Call Provider Services for more information about whether a specific procedure code is subject to these reimbursement limits.
Multiple Births
Reimbursement for multiple births is dependent on the circumstances of the deliveries. If all deliveries are vaginal or if all are Cesarean, the first delivery is reimbursed at 100 percent of ForwardHealth's maximum allowable fee for the service. The second delivery is reimbursed at 50 percent, the third at 25 percent, and subsequent deliveries at 13 percent each.
In the event of a combination of vaginal and Cesarean deliveries, the delivery with the largest billed amount is reimbursed at 100 percent, the delivery with the next largest at 50 percent, and so on, consistent with the policy for other situations of multiple surgeries.
For example, if the initial delivery of triplets is vaginal and the subsequent two deliveries are Cesarean, the first Cesarean delivery is reimbursed at 100 percent, the second Cesarean delivery at 50 percent, and the vaginal delivery at 25 percent.
Preoperative and Postoperative Care
Reimbursement for certain surgical procedures includes the preoperative and postoperative care days associated with that procedure. Preoperative and postoperative surgical care includes the preoperative evaluation or consultation, postsurgical E&M services (i.e., hospital visits, office visits), suture, and cast removal.
Note: Separate reimbursement is allowed for postoperative management when it is performed by a provider other than the surgeon or shared with the surgeon following cataract surgery.
All primary surgeons, surgical assistants, and co-surgeons are subject to the same preoperative and postoperative care limitations for each procedure. For surgical services in which a preoperative period applies, the preoperative period is typically three days. Claims for services that fall within the range of established pre-care and post-care days for the procedure(s) being performed are denied unless they indicate a circumstance or diagnosis code unrelated to the surgical procedure.
For the number of preoperative and postoperative care days applied to a specific procedure code, call Provider Services. |