May 3, 2018
New claims edits will become effective for professional claims processed on or after June 15, 2018. As a follow up to the Provider News article on March 15, here’s key information about the claims edits.
Correct Submission of Add-On Codes: Add-on codes, designated by the plus symbol (+) in the CPT Codebook, are never billed alone but always with an appropriate primary code. If you submit an add-on code without an appropriate primary code, your add-on code claim line will be denied and you’ll have to resubmit your claim.
To prepare for this upcoming edit, review the list of add-on codes in a current CPT codebook. These codes can be found in Appendix D in the codebook or found throughout the codebook marked with the symbol “+” next to the code. There will be a parenthetical note after the add-on code identifying the appropriate primary code(s). We’ll release a new payment policy on add-on codes before the effective date of the claims edit.
Global Period Post-Operative Surgeries: Sometimes it’s necessary to bring a patient back into the Operating Room (OR) for another surgical procedure. That surgical procedure may or may not be related to a prior major or minor surgery performed earlier or it may be a staged procedure planned as part of the original surgery.
When it’s necessary to return a patient to the OR during the global period of a prior surgery (10, 45 or 90 day post-operative period), you’ll need to identify the circumstances of the return visit. You’ll need to append an appropriate modifier to the surgery, indicating that it’s being performed during the established global period of a prior surgery. The key modifiers to use are:
- Modifier 58-Staged Procedure during Global Period
Use this modifier to indicate that the physician who performed the original surgery prospectively planned to return the patient to the operating room for additional surgery during the original surgery’s global period. Don’t append this modifier to code descriptions that already indicate multiple sessions or procedures
- Modifier 78 – Unplanned Return to the Operating Room for Related Procedure during the Global Period
Use this modifier to indicate an unplanned return to the operating room. This unplanned return could be for treatment for complications related to the original surgery or for a surgery related to the original surgery that started the global period. The decision to return the patient to the operating room is made by the same physician who conducted the original surgery.
- Modifier 79 – Unrelated surgical procedure during the Global Period
Use this modifier to indicate that the provider who performed the original surgery performed an additional procedure or service during the global period that is unrelated to the original procedure, typically involving a different anatomic location.
Procedures with Global or 26/TC modifier splits: We follow the breakout of “technical” and “professional” services as designated on the National Physician Fee Schedule, maintained by CMS. If you render just the technical or the professional service for one of these codes, you’ll need to add the correct modifier (26 for professional services or TC for technical services).
We will be enforcing these modifier requirements on both professional and facility/hospital claims. If we already paid for a global submission of a code, the new edit will deny reimbursement of the individual submissions of the professional and/or technical versions of the code. If we already paid for the professional and/or the technical version of the code, the new edit will deny the submission of the global service.
To prepare for the upcoming edits, review your codebooks and the National Physician Fee Schedule for additional information.