evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Exclude the following codes from the prepayment edits required in 40.3.B .  92002  92004  99201  99202  99203  99204  99205  99281  99282  99283  99284  99285  99321  99322  99323  99341  99342  99343  99344  99345       40.4 - Adjudication of Claims for Global Surgeries  (Rev . 11287; Issued:03- 02-22; Effective:01 -01-22; Implementation: 02 -22-22)   A.  Fragmented Billing of Services Included in the Global Package   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 th e global fee, process the claim as a fee schedule reduction (except where stated policies, e.g., the surgeon performs only 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, pricing  for  -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.
(Medicare Claims Processing Manual)
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.    Critical care services furnished during the global period must be unrelated to the procedure. Separate payment is allowed for unrelated visits when the - FT modifier ((unrelated evaluation and management (E/M) visit on the same day as another E/M visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable). (Report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated.)) is appended.  See section 30.6.12.7 of this chapter for further discussion of critical care visits unrelated to the procedure with a global surgical period.   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,  -57 or  -FT. 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 or  -FT but without sufficient documentation.  These services should also be denied.  Modifier  -24 or  -FT 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 documentation demonstrates that the visit occurred during a subsequent hospitalization and the diagnosis supports the fact that it is unrelated to the original surgery.
(Medicare Claims Processing Manual)
 The care is for immunotherapy management furnished by the transplant surgeon;    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.   A/B MACs (B) do not allow separate payment for an additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior procedure and if billed without modifier  -58,  -78, or  -79.  These services should be de nied.  Codes with the global surgery indicator of XXX in the MFSDB can be paid separately without a modifier.  B.  Claims From Physicians Who Furnish Less Than the Global Package (Split Global Care)   For surgeries performed January 1, 1992, and later, that are billed with either modifier  -54 or -55, A/B MACs (B) pay the appropriate percentage of the fee schedule payment.  Fields 17-19 of the MFSDB list the appropriate percentages for pre -, intra -, and postoperative care of the total RVUs for major surgical procedures and for minor surgeries with a postoperative period of 10 days.  The intra -operative percentage includes postoperative  hospital visits.   Procedures with a 000 entry in Field 16 have an entry of 0.0000 in Fields 17- 19.  Split global care does not apply to these procedures.   A/B MACs (B) multiply the fee schedule amount (Field 34 or Field 35 of the MFSDB) by this percentage and round to the nearest cent.  Assume that a physician who bills with a  -54 modifier has provided both preoperative, intra -operative and postoperative hospital  services.  Pay this physician the combined preoperative and intra -operative portions of the fee schedule payment amount.  Where more than one physician bills for the postoperative care, A/B MACs (B) apportion the postoperative percentage according to the number of days each physician was responsible for the patients care by dividing the postoperative allowed amount by the number of post -op days and that amount is multiplied by the number of days each physician saw the patient.   EXAMPLE
(Medicare Claims Processing Manual)
EXAMPLE   Dr. Jones bills for procedure 42145- 54 performed on March 1 and states that he cared for the patient through April 29.  Dr.  Smith bills for procedure 42145 -55 and states that she assumed care of the patient on April 30.  The percentage of the total fe e amount for the postoperative care for this procedure is determined to be 17 percent and the length of the global period is 90 days.  Since Dr. Jones provided postoperative care for the first 60 days, he will receive 66 2/3 percent of the total fee of 17 percent since 60/90 = .6666.  Dr. Smiths 30 days of service entitle her to 30/90 or .3333 of the fee.   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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(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 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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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
(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 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 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
(Medicare Claims Processing Manual)
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 s urgery.  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 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