evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
 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
(Medicare Claims Processing Manual)
A/B MACs (B) must be able to:  1. Identify multiple surgeries by both of the following methods:   The presence on the claim form or electronic submission of the  -51 modifier; and  The billing of more than one separately payable surgical procedure by the same physician performed on the same patient on the same day, whether on different lines or with a number greater than 1 in the units column on the claim form or inappropriately bill ed with modifier  -78 (i.e., after the global period has expired);  2. Access Field 34 of the MFSDB to determine the Medicare fee schedule payment amount for each surgery;  3. Access Field 21 for each procedure of the MFSDB to determine if the payment rules for multiple surgeries apply to any of the multiple surgeries billed on the same day;  4. If Field 21 for any of the multiple procedures contains an indicator of 0, the multiple surgery rules do not apply to that procedure.  Base payment on the lower of the billed amount or the fee schedule amount (Field 34 or 35) for each code unless othe r payment adjustment rules apply;  5. For dates of service prior to January 1, 1995, if Field 21 contains an indicator of 1, the standard rules for pricing multiple surgeries apply (see items 6- 8 below);  6. Rank the surgeries subject to the standard multiple surgery rules (indicator 1) in descending order by the Medicare fee schedule amount;  7. Base payment for each ranked procedure on the lower of the billed amount, or:   100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure;   50 percent of the fee schedule amount for the second highest valued procedure; and  25 percent of the fee schedule amount for the third through the fifth highest valued procedures;  8. If more than five procedures are billed, pay for the first five according to the rules listed in 5, 6, and 7 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, by report.  Payment determined on a by r eport basis for these codes should never be lower than 25 percent of the full payment amount;  9. For dates of service on or after January 1, 1995, new standard rules for pricing multiple surgeries apply.  If Field 21 contains an indicator of 2, these new standard rules apply (see items
(Medicare Claims Processing Manual)
percent of the full payment amount;  9. For dates of service on or after January 1, 1995, new standard rules for pricing multiple surgeries apply.  If Field 21 contains an indicator of 2, these new standard rules apply (see items 10 -12 below);  10. Rank the surgeries subject to the multiple surgery rules (indicator 2) in descending order by the Medicare fee schedule amount;  11. Base payment for each ranked procedure (indicator 2) on the lower of the billed amount:   100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure; and   50 percent of the fee schedule amount for the second through the fifth highest valued procedures; or  12. If more than five procedures with an indicator of 2 are billed, pay for the first five according to the rules listed in 9, 10, and 11 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, by report.  Payment determined on a by report basis for these codes should never be lower than 50 percent of the full payment amount.  Pay by the unit for services that are already reduced (e.g., 17003).  Pay for 17340 only once per session, regardless of how many lesions were destroyed;  NOTE:  For dates of service prior to January 1, 1995, the multiple surgery indicator of 2 indicated that special dermatology rules applied.  The payment rules for these codes have not changed.  The rules were expanded, however, to all codes that previously had a multiple surgery indicator of 1.  For dates of service prior to January 1, 1995, if a dermatological procedure with an indicator of 2 was billed with the  -51 modifier with other procedures that are not  dermatological procedures (procedures wi th an indicator of 1 in Field 21), the standard multiple surgery rules applied.  Pay no less than 50 percent for the dermatological procedures with an indicator of 2.  See 40.6.C.6- 8 above for required actions. 13. If Field 21 contains an indicator of 3, and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply.  Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy.  Access Field 31A of the MFSDB to
(Medicare Claims Processing Manual)
the special rules for multiple endoscopic procedures apply.  Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy.  Access Field 31A of the MFSDB to determine the base endoscopy.  EXAMPLE  In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon.  The physician bills for codes 45380 and 45385.  The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in.  Rather than paying 100 percent for the highest valued procedure (45385) and 50 percent for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378). A/B MACs (B) assume the following fee schedule amounts for these codes:  45378 -  $255.40 45380 -  $285.98 45385 -  $374.56 Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14.   NOTE : If an endoscopic procedure with an indicator of 3 is billed with the -51 modifier with other procedures that are not  endoscopies (procedures with an indicator of 1 in Field 21), the standard multiple surgery rules apply.  See 40.6.C.6-8 above for required actions. 14. Apply the following rules where endoscopies are performed on the same day as unrelated endoscopies or other surgical procedures:  Two unrelated endoscopies (e.g., 46606 and 43217):  Apply the usual multiple surgery rules;  Two sets of unrelated endoscopies (e.g., 43202 and 43217; 46606 and 46608):  Apply the special endoscopy rules to each series and then apply the multiple surgery rules.  Consider the total
(Medicare Claims Processing Manual)
unrelated endoscopies (e.g., 43202 and 43217; 46606 and 46608):  Apply the special endoscopy rules to each series and then apply the multiple surgery rules.  Consider the total payment for each set of endoscopies as one service;   Two related endoscopies and a third, unrelated procedure:  Apply the special endoscopic rules to the related endoscopies, and, then apply the multiple surgery rules.  Consider the total payment for the related endoscopies as one service and the unrelated endoscopy as another service. 15. If two or more multiple surgeries are of equal value, rank them in descending dollar order billed and base payment on the percentages listed above (i.e., 100 percent for the first billed procedure, 50 percent for the second, etc.); 16. If any of the multiple surgeries are bilateral surgeries, consider the bilateral procedure at 150 percent as one payment amount, rank this with the remaining procedures, and apply the appropriate multiple surgery reductions.  See 40.7
(Medicare Claims Processing Manual)
for bilateral surgery payment instructions.); 17. Round all adjusted payment amounts to the nearest cent; 18. If some of the surgeries are subject to special rules while others are subject to the standard rules, automate pricing to the extent possible.  If necessary, price manually; 19. In cases of multiple interventional radiological procedures, both the radiology code and the primary surgical code are paid at 100 percent of the fee schedule amount.  The subsequent surgical procedures are paid at the standard multiple surgical percentages (50 percent, 50 percent, 50 percent and 50 percent); 20. Apply the requirements in 40
(Medicare Claims Processing Manual)
on global surgeries to multiple surgeries; 21. Retain the -51 modifier in history for any multiple surgeries paid at less than the full global amount; and 22. Follow the instructions on adjudicating surgery claims submitted with the -22 modifier.  Review documentation to determine if full payment should be made for those distinctly different, unrelated surgeries performed by different physicians on the sam e day. D. Ranking of Same Day Multiple Surgeries When One Surgery Has a  -22 Modifier and Additional Payment is Allowed  B3-4826 If the patient returns to the operating room after the initial operative session on the same day 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 apply. However, 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 complications rules would apply.  The multiple surgery rules would also not apply. Multiple surgeries are defined as 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, sur gical 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.  40.7 - Claims for Bilateral Surgeries  (Rev. 1, 10- 01-03) B3-4827, B3- 15040 A. General  Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day.  The terminology for some procedure codes includes the terms bilateral (e.g., code 27395; Lengthening of the hamstring tendon; multiple, bilateral.) or unilateral or bilateral (e.g., code 52290; cystourethroscopy; with ureteral meatotomy, unilateral
(Medicare Claims Processing Manual)
tendon; multiple, bilateral.) or unilateral or bilateral (e.g., code 52290; cystourethroscopy; with ureteral meatotomy, unilateral or bilateral).  The payment adjustment rules for bilateral surgeries do not apply to procedures identified by CPT  as bilateral or unilateral or bilateral since the fee schedule reflects any additional work required for bilateral surgeries.  Field 22 of the MFSDB indicates whether the payment adjustment rules apply to a surgical procedure.  B. Billing Instructions for Bilateral Surgeries  If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral), physicians must report the procedure with modifier  -50.  They report such procedures as a single line item.  ( NOTE :  This differs from the CPT coding guidelines which indicate that bilateral procedures should be billed as two line items.)  If a procedure is identified by the terminology as bilateral (or unilateral or bilateral), as in codes 27395 and 52290, physicians do not report the procedure with modifier  -50. C. Claims Processing System Requirements  A/B MACs (B) must be able to: 1. Identify bilateral surgeries by the presence on the claim form or electronic submission of the  -50 modifier or  of the same code on separate lines reported once with modifier -LT and once with modifier  -RT;  2. Access Field 34 or 35 of the MFSDB to determine the Medicare payment amount;  3. Access Field 22 of the MFSDB:   If Field 22 contains an indicator of 0, 2, or 3, the payment adjustment rules for bilateral surgeries do not apply.  Base payment on the lower of the billed amount or 100 percent of the fee schedule amount (Field 34 or 35) unless other payment adjust ment rules apply.   NOTE:   Some codes which have a bilateral indicator of 0 in the MFSDB may be performed more than once on a given day.  These are services that would never be considered bilateral and thus should not be billed with modifier  -50.  Where such a code is billed o n multiple line items or with more than 1 in the units field and A/B MACs (B) have determined that the code may be reported more than once, bypass the
(Medicare Claims Processing Manual)
modifier  -50.  Where such a code is billed o n multiple line items or with more than 1 in the units field and A/B MACs (B) have determined that the code may be reported more than once, bypass the 0 bilateral indicator and refer to the multiple surgery field for pricing;   If Field 22 contains an indicator of 1, the standard adjustment rules apply.  Base payment on the lower of the billed amount or 150 percent of the fee schedule amount (Field 34 or 35).  (Multiply the payment amount in Field 34 or 35 for the surgery by 150 percent and round to the nearest cent.)  4. Apply the requirements 40 - 40.4  on global surgeries to bilateral surgeries; and 5. Retain the -50 modifier in history for any bilateral surgeries paid at the adjusted amount. (NOTE:   The -50 modifier is not retained for surgeries which are bilateral by definition such as code 27395.) 40.8. - Claims for Co -Surgeons and Team Surgeons  (Rev. 3721, Issued: 02- 24-17, Effective: 05-25-17, Implementation: 05-25-17)
(Medicare Claims Processing Manual)
A.  General   Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session.  This may be required because of the complex nature of the procedure(s) and/or the patients condition.  In these cases, the additional physicians are not acting as assistants -at-surgery.  B.  Billing Instructions   The following billing procedures apply when billing for a surgical procedure or procedures that required the use of two surgeons or a team of surgeons:   If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier -62.  Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements.  Documentation of the medical necessity for two surgeons is required for certain services identified in the MFSDB.  (See 40.8.C.5.);   If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier -66.  Field 25 of the MFSDB identifies certain services submitted with a  -66 modifier which must be sufficiently documented to establish that a team was medically necessary.  All claims for team surgeons must contain sufficient information to allow pricing by report.   If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co -surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision).  If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeons services.  (See 40.6 for multiple surgery payment rules.)  For co -surgeons (modifier 62), the fee schedule amount applicable to the payment for each  co-surgeon is 62.5 percent of the global surgery fee schedule amount.  Team surgery (modifier 66) is paid for on a By Report basis.  C.  Claims Processing System Requirements  Carriers must be able to:   1. Identify a surgical procedure performed by two surgeons or a team of surgeons by the presence on the claim form or electronic submission of the -62 or - 66 modifier;   2. Access Field 34 or 35 of the MFSDB to determine the fee schedule payment amount for the surgery;
(Medicare Claims Processing Manual)
2. Access Field 34 or 35 of the MFSDB to determine the fee schedule payment amount for the surgery;  3. Access Field 24 or 25, as appropriate, of the MFSDB.  These fields provide guidance on whether two or team surgeons are generally required for the surgical procedure;  4. If the surgery is billed with a -62 or -66 modifier and Field 24 or 25 contains an indicator of 0, payment adjustment rules for two or team surgeons do not apply:   Carriers pay the first bill submitted, and base payment on the lower of the billed amount or 100 percent of the fee schedule amount (Field 34 or 35) unless other payment adjustment rules apply;   Carriers deny bills received subsequently from other physicians and use the appropriate MSN message in 40.8.D.   As these are medical necessity denials, the instructions in the Program Integrity Manual regarding denial of unassigned claims for medical necessity are applied;   5. If the surgery is billed with a -62 modifier and Field 24 contains an indicator of 1, suspend the claim for manual review of any documentation submitted with the claim.  If the documentation supports the need for co-surgeons, base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount (Field 34 or 35);  6. If the surgery is billed with a -62 modifier and Field 24 contains an indicator of 2, payment rules for two surgeons apply.  Carriers base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount (Field 34 or 35);  7. If the surgery is billed with a -66 modifier and Field 25 contains an indicator of 1, carriers suspend the claim for manual review.  If carriers determine that team surgeons were medically necessary, each physician is paid on a by report basis;  8. If the surgery is billed with a -66 modifier and Field 25 contains an indicator of 2, carriers pay by report;
(Medicare Claims Processing Manual)
NOTE:  A Medicare fee may have been established for some surgical procedures that are billed with the  -66 modifier.  In these cases, all physicians on the team must agree on the percentage of the Medicare payment amount each is to receive.  If carriers receive a bill with a  -66 modifier after carriers have paid one surgeon the full Medicare payment amount (on a bill without  the modifier), deny the subsequent claim.  9. Apply the rules global surgical packages to each of the physicians participating in a co- or team surgery; and  10. Retain the -62 and -66 modifiers in history for any co- or team surgeries.   D.  Beneficiary Liability on Denied Claims for Assistant, Co- surgeon and Team Surgeons   When the procedure is subject to the statutory restriction against payment for assistants- at-surgery, such payment shall be denied.  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: 54  RARC: N/A  MSN: 15.11   Carriers include the following statement in the MSN: "You cannot be charged for this service. (Unnumbered add -on message.)   If Field 23 of the MFSDB contains an indicator of 0 or 1 (assistant -at-surgery may not be paid) for procedures CMS has determined that an assistant surgeon is not generally medically necessary.   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: 54  RARC: N/A  MSN: 15.12  For those procedures with an indicator of 0, the limitation on liability provisions described in Chapter 30 apply to assigned claims.  Therefore, carriers include the appropriate limitation of liability language from Chapter 21.  For unassigned claims, apply the rules in the Program Integrity Manual concerning denial for medical necessity. Where payment may not be made for a co - or team surgeon, deny the claim   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.
(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: 54  RARC: N/A  MSN: 15.13  Where payment may not be made for a two surgeons, deny the claim.   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: 54  RARC: N/A  MSN: 15.12  Also see limitation of liability remittance notice Remittance Advice Remark Code Alert M27 and use when appropriate.