(Medicare Claims Processing Manual)

The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: B15  RARC: N/A  MSN: 23.1  2.  Messages for Global Packages Split Between Two or More Physicians   When a physician furnishes only the pre - and intra -operative services, but bills for the entire package:   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: B20  RARC: N/A  MSN: 23.5  3.  Message for Procedure Codes With ZZZ Global Period Billed as Stand -Alone Procedures   When a physician bills for a surgery with a ZZZ global period without billing for another service:   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 4.   Group Code: CO  CARC: 234  RARC: N390  MSN: 9.2, 9.3  4.   Message for Payment Amount When Modifier - 22 Is Submitted Without Documentation   When a physician submits a claim with modifier  -22 but does not provide additional documentation:   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 1.   Group Code: CO  CARC: 252  RARC: N706  MSN: 9.7  40.5 - Postpayment Issues (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  It may not always be possible to identify instances where more than one physician furnishes postoperative care before the carrier has paid at least one of the physicians.  In addition, situations where a physician renders less than the full global package but does not add the applicable modifier to the procedure code are not detectable until another physician submits a claim.   Several other categories of fragmented bills cannot be or are difficult to detect on a prepayment basis.  When a new claim reveals fragmented billing by a single provider after payment for some services was already made to that physician, carriers must adj ust the amount due on the new claim by the amount previously paid.  When a new claim indicates that an incorrect payment may have been made to another physician who submitted a previous bill, carriers must determine which bill is correct.  (Review the claims and any submitted records to be sure that the providers correctly used modifiers and are billing for services that are included in the global fee.  If necessary, a carrier representative must contact one or both physicians to determine which claim is correct.) If the carrier determines that the first claim is incorrect,  they follow the overpayment procedures in the Medicare Financial Management Manual, Chapter 3, for recovery of the incorrect payment from the first physician.  They pay the second physician according to the services performed.  If the carrier determines t hat the second claim is incorrect, they deny payment.  The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: B20  RARC: N/A  MSN: 7.3  Carriers must include the appropriate language regarding beneficiary liability according to 40.4.D , above.   Nonparticipating physicians who furnish less than the full global package, but who bill for the entire global surgery, may be guilty of violating their charge limits.  In addition, physicians who engage in such practices may be guilty of fraud.  See the Me dicare Financial Management Manual, Chapter 3, and the Medicare Program Integrity Manual, Chapter 3, for further information on recovery of overpayments, charge limit monitoring, and fraud.  40.6 - Claims for Multiple Surgeries  (Rev. 1, 10- 01-03) B3-4826, B3- 15038, B3- 15056  A. General   Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed.  Co -surgeons, surgical teams , or assistants -at-surgery may participate in performing multiple surgeries on the same patient on the same day.   Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure.  These intra -operative services, incidental surgeries, or components of more major surgeries are not separately billable.  See Chapter 23 for a description of mandatory edits to prevent separate payment for those procedures.  Major surgical procedures are determined based on the MFSDB approved amount and not on the submitted amount from the providers.  The major surgery, as based on the MFSDB, m ay or may not be the one with the larger submitted amount.   Also, see subsection D below for a description of the standard payment policy on multiple surgeries.  However, these standard payment rules are not appropriate for certain procedures.  Field 21 of the MFSDB indicates whether the standard payment policy rul es apply to a multiple surgery, or whether special payment rules apply.  Site of service payment adjustments (codes with an indicator of 1 in Field 27 of the MFSDB) should be applied before multiple surgery payment adjustments.  B. Billing Instructions  The following procedures apply when billing for multiple surgeries by the same physician on the same day.    Report the more major surgical procedure without the multiple procedures modifier  -51.  Report additional surgical procedures performed by the surgeon on the same day with modifier  -51.  There may be instances in which two or more physicians each perform distinctly different, unrelated surgeries on the same patient on the same day (e.g., in some multiple trauma cases).  When this occurs, the payment adjustment rules for multiple surgeries may not be appropriate.  In such cases, the physician does not use modifier  -51 unless one of the surgeons individually performs multiple surgeries.   C. A/B MAC (B) Claims Processing System Requirements