Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that A/B MACs (B) do not allow separate payment for visits during the postoperative period that are billed with the modifier "-24" but without sufficient documentation. These services should also be denied. Modifier "-24" is intended for use with services that are absolutely unrelated to the surgery. It is not to be used for the medical management of a patient by the surgeon following surgery. Recognize modifier "-24" only for care following discharge unless: - The care is for immunotherapy management furnished by the transplant surgeon; - The care is for critical care for a burn or trauma patient; or - The documentation demonstrates that the visit occurred during a subsequent hospitalization and the diagnosis supports the fact that it is unrelated to the original surgery. We are still unable to approve your request. You can find thisinformation in Medicare's IOM 100-04, Chapter 12, Section 40.4.A.The rules say that since the Medicare fee schedule amount for surgical procedures includes all services that are part of the global surgery package, A/B MACs (B) do not pay more than that amount when a bill is fragmented.  When total charges for fragmented services exceed the global fee, process the claim as a fee schedule reduction (except where stated policies, e.g., the surgeon performsonly the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care, result in payment that is higher than the global surgery allowed amount).  A/B MACs (B) do not attribute such reductions to medical review savings except where the usual medical review process results in recoding of a service, and the recoded service is included in the global surgery package.The maximum a nonparticipating physician may bill a beneficiary on an unassigned claim for services included in the global surgery package is the limiting charge for the surgical procedure.In addition, the limitation of liability provision (1879 of the Act) does not apply to these determinations since they are fee schedule reductions, not denials based upon medical necessity or custodial care.Claims for surgeries billed with a "-22" or "-52" modifier, are priced by individual consideration if the statement and documentation required by 40.2.A.10 are included.  If the statement and documentation are not submitted with the claim, pricingfor "-22" is it the fee schedule rate for the same surgery submitted without the "-22" modifier.  Pricing for "-52" is not done without the required documentation.Separate payment is allowed for visits and procedures billed with modifier "-78," "-79," "-24," "-25," "-57," or"-58."  Modifier "-24" must be accompanied by sufficient documentation that the visit is unrelated to the surgery.  Also, when used with the critical care codes, modifiers "-24" and "-25" must be accompanied by documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed.A/B MACs (B) do not allow separate payment for evaluation and management services furnished on the same day or during the postoperative period of a surgery if the services are billed without modifier "-24," "-25," or "-57."  These services should be denied.  A/B MACs (B) do not allow separate payment for visits during the postoperative period that are billed with the modifier "-24" but without sufficient documentation. These services should also be denied.  Modifier "-24" is intended for use with services that are absolutely unrelated to the surgery.  It is not to be used for the medical management of a patient by the surgeon following surgery. You can find this information is the Medicare Claims Processing Manual.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.