Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27481

Co-Management of Surgical Procedures

L27481

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

This policy addresses the indications and limitations of the co-management of surgical procedures that have a 10-day or 90-day global care period. It also provides guidelines for proper billing and documentation.

Management of a surgical procedure is the primary responsibility of the operating surgeon. Physicians who perform surgery and furnish all of the usual pre and post-operative work should bill for global surgical care by using the proper CPT surgical code(s). Physicians should not bill separately for visits or other services that are included in the global package.

Occasionally a physician must transfer the care of the patient during the global care period. In these instances, modifier 54 and 55 are used to distinguish who is providing care for the patient.

• Modifier 54 – Surgical Care only

This modifier is used by the surgeon and when another physician provides preoperative and postoperative care. This modifier is appended to the surgical procedure code.

• Modifier 55 – Postoperative Management Only

This modifier is used by the physician who provides postoperative care when another physician has done the surgical procedure. This modifier is also appended to the surgical procedure code.

The physician receiving the patient must be licensed to manage all aspects of the postoperative care, including the ability to diagnose potential complications that would require another operation.

In all instances the transfer of global surgery must be clinically necessary and appropriate. The transfer of surgical care is allowed only to protect the legitimate interest of the beneficiary as outlined in below under Indications and Limitations.

Indications

Co-management is indicated in any of the following circumstances:

• The operating surgeon is unavailable after surgery and the patient’s post-operative care has to be managed by another physician.
• The beneficiary is unable to travel the distance to the surgeon’s office for postoperative care visits.
• The patient voluntarily wishes to be followed postoperatively by another physician.
• The surgery is performed by an itinerant surgeon in a remote area of the country.
• The care is provided in a health professional shortage area (HPSA) and the beneficiary is unable to travel to the surgeon’s office.
• The surgeon practices in a site remote from where the patient recuperates, e.g., the surgery is performed in a remote area and the surgeon does not return to the area frequently enough to provided the preoperative or postoperative care.
• A second illness has developed which prevents the patient from traveling to the operating surgeon.
• A surgery is performed at a far away site or while the patient is traveling, vacationing, or temporarily living in a distant location.

Limitations

The transfer of postoperative care is not covered if:

• The operating surgeon is available and he/she is able to manage other patients postoperatively, unless the patient voluntarily wishes to be followed postoperatively by another provider.
• The surgeon does follow the patient postoperatively but splits the fee with another provider.
• Two or more physicians co-manage patients indiscriminately as a matter of policy and not on a case-by-case basis.
• A physician demands to manage the postoperative care and indicates that he/she will withhold making referrals to surgeons who would not agree to split global surgery payments.
• A surgeon opts to transfer postoperative management but follows the patient postoperatively as he/she would have done without transferring postoperative care.
• The transfer is not made in writing.
• The transfer of care is used as an incentive for obtaining referrals from providers to receive postoperative care reimbursement.
• The patient has not consented to transfer of care even after being apprised of the medical and/or logistic advisability or the risks and benefits of transfer care.

A claim for co-management will be denied if:

• Any of the circumstances listed in the “Limitations” subsection of this policy apply.
• The medical record documentation does not support the “Documentation Requirements” section of this policy.

Surgical Services

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
   
   
4. The surgeon should write his/her usual operative note. The physician providing postoperative care should document appropriate follow-up care notes.
   
   
5. Transfer of care must be in writing and dated. The record must indicate the exact date on which post-operative care is assumed by the co-managing physician.
   
   
6. Additionally, the medical record must indicate that the patient was appropriately informed of the medical and/or logistic advisability of transfer of care along with any risks or benefits of this arrangement, and that the patient gave consent to this arrangement prior to its inception.
   
   
7. The documentation that the patient was properly informed as described above, must be made available to Medicare upon request.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27481

05/22/2008

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