Surgery Guidelines

(1) Multiple Procedures: Maximum reimbursement shall be based on 100% of the appropriate Medical Fee Schedule amount listed in the rate tables for the major procedure plus each additional appropriately coded secondary and/or multiple procedures according to Medicare guidelines (including endoscopy and other applicable “families”) and NCCI edits. (2) Services Rendered by More Than One Physician: (a) Concurrent Care: One attending physician shall be in charge of the care of the injured employee. However, if the nature of the injury requires the concurrent services of two or more specialists for treatment, then each physician shall be entitled to the listed fee for services rendered. (b) Surgical Assistant: A physician who assists at surgery may be reimbursed as a surgical assistant. To identify surgical assistant services provided by physicians, Modifier 80, MEDICAL FEE SCHEDULE CHAPTER 0800-02-18 81, or 82 shall be added to the surgical procedure code which is billed. A physician serving as a surgical assistant shall submit a copy of the operative report to substantiate the services rendered. Reimbursement is limited to the lesser of the surgical assistant’s usual charge or 20% of the maximum allowable Medical Fee Schedule amount. Procedures billed with the assistant-at-surgery modifiers are subject to Medicare guidelines for this service. 1. Appropriately licensed Physician Assistants and Advance Practice Nurses (Nurse Practitioners) may serve as surgical assistants as deemed appropriate by the physician, and if so, that assistant’s reimbursement shall not exceed 85% of the maximum allowable reimbursement listed on the rate table for an assistant surgeon billed with modifier 80. These services shall be billed using the -AS modifier and are subject to the applicable Medicare assistant-at-surgery guidelines. 2. Two Surgeons: For reporting see the most current edition of the CPT® book. Each surgeon shall submit an operative report documenting the specific surgical procedure(s) provided. Each surgeon shall submit an individual bill for the services rendered. Reimbursement shall not be made to either surgeon until the employer has received each surgeon’s individual operative report and bill. Reimbursement to each surgeon shall be the lesser of billed charges or 62.5% of the maximum allowable reimbursement listed in the rate tables. 3. The need for a surgical assistant, assisting surgeon, co-surgeon, second surgeon or team surgery will follow Medicare status indicators. The payment amount will be adjusted for selected specialties as designated in 0800-02-18- .02(4) and (5) and 0800-02-18-.04(2). (3) When a surgical fee is chargeable, no office visit charge shall be allowed for the day on which this surgical fee is earned, except if surgery is performed on the same day as the physician’s first examination, in accord with Medicare guidelines in effect for the date of service. All exceptions require use of the appropriate modifiers. (4) Certain of the listed procedures in the Medical Fee Schedule are commonly carried out as an integral part of a total service and, as such, do not warrant a separate charge, commonly known as a global fee. Lacerations ordinarily require no aftercare except removal of sutures. The removal is considered a routine part of an office or hospital visit and shall not be billed separately unless such sutures are removed by a provider different from the provider administering the sutures.