Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for code 12011 billed for services provided on June 22, 2022.
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that per the Medicare lobal Surgery Booklet, Post-Operative Period Billing - Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period, two modifiers are used to simplify billing for visits and other procedures that are furnished during the post-operative period of a surgical procedure, but not included in the payment for surgical procedure. These modifiers are modifier "-79" (Unrelated procedure or service by the same physician during a post-operative period). The physician may need to indicate that a procedure or service furnished during a post-operative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed. Or modifier "-24" (Unrelated E/M service by the same physician during a post-operative period).
The physician may need to indicate that an evaluation management (E/M) service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier "-24" must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure. This same information is included in Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners, Section 40.2 A7 - Unrelated Procedures or Visits During the Postoperative Period. Per the Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners, Section 40.2 A2 - Physicians in Group Practice, when different physicians in a group practice participate in the care of the enrollee, the group bills for the entire global package if the physicians reassign benefits to the group. The physician who performs the surgery is shown as the performing physician. (For dates of service prior to January 1, 1994, however, where a new physician furnishes the entire postoperative care, the group billed for the surgical care and the postoperative care as separate line items with the appropriate modifiers.) The Plan notes that both providers are part of the same group practice, share the same specialty of Emergency Medicine, and both claims were billed with the same Taxonomy code of 207P0000X. As such, they are considered the same provider for Medicare billing purposes. As the provider did not bill either Modifier 79 or 24 to indicate an Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period, they did not bill according to Medicare coding guidelines.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim under appeal could not be paid due to the omission of a required modifier to show this was an unrelated service. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 12011 billed for services provided on June 22, 2022.