(Medicare Claims Processing Manual)

6666 x .17 = .11333 or 11.3%; and   3338 x .17 = .057 or 5.7%.  Thus, Dr. Jones will be paid at a rate of 11.3 percent (66.7 percent of 17 percent).  Dr.  Smith will be paid at a rate of 5.7 percent (33.3 percent of 17 percent).   C.  Payment for Return Trips to the Operating Room for Treatment of Complications   When a CPT code billed with modifier  -78 describes the services involving a return trip to the operating room to deal with complications, A/B MACs (B) pay the value of the intra -operative services of the code that describes the treatment of the complicat ions.  Refer to Field 18 of the MFSDB to determine the percentage of the global package for the intra -operative services.  The fee schedule amount (Field 34 or 35 of the MFSDB) is multiplied by this percentage and rounded to the nearest cent.   When a procedure with a 000 global period is billed with a modifier  -78, representing a return trip to the operating room to deal with complications, A/B MACs (B) pay the full value for the procedure, since these codes have no pre -, post -, or intra -operative values.   When an unlisted procedure is billed because no code exists to describe the treatment for complications, A/B MACs (B) base payment on a maximum of 50 percent of the value of the intra-operative services originally performed.  If multiple surgeries were ori ginally performed, A/B MACs (B) base payment on no more than 50 percent of the value of the intra -operative services of the surgery for which the complications occurred.  They multiply the fee schedule amount for the original surgery (Field 34 or 35) by the intra -operative percentage for the procedure (Field 18), and then multiply that figure by 50 percent to obtain the maximum payment amount.  [.50 X (fee schedule amount x intra -operative percentage)].  Round to the nearest cent.   If additional procedures are performed during the same operative session as the original surgery to treat complications which occurred during the original surgery, A/B MACs (B) pay the additional procedures as multiple surgeries.  Only surgeries that requi re a return to the operating room are paid under the complications rules.  If the patient is returned to the operating room after the initial operative session, but on the same day as the original surgery for one or more additional procedures as a result of complications from the original surgery, the complications rules apply to each procedure required to treat the complications from the original surgery.  The multiple surgery rules would not also apply.  If the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for multiple procedures that are required as a result of complications from the original surgery, the com plications rules would apply.  The multiple surgery rules would also not apply. If the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for bilateral procedures that are required as a result of complications from the original surgery, the complication rules would apply.  The bilateral rules would not apply.  D.  MSN and Remittance Messages   When A/B MACs (B) deny separate payment for a visit because it is included in the global package, include one of the following statements on the MSN to the beneficiary and the remittance notice sent to the physician.    1.  Messages for Fragmented Billing by a Single Physician   When a single physician bills separately for services included in the global surgical package which has already been billed:   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: 97  RARC: N/A  MSN: 23.1  When a single physician bills separately for services included in the global surgical package which has not yet been billed/adjudicated:   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, may 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