Mississippi Administrative Code › Title 20 - Labor › Part 2 - Mississippi Workers' Compensation Medical Fee Schedule › SURGERY › Section 20-2-I - GENERAL GUIDELINES

Current through June 25, 2024
A.
Global
				Reimbursement.
The reimbursement allowances for surgical procedures are
				based on a global reimbursement concept that covers performing the basic
				service and the normal range of care required after surgery. The State of
				Mississippi follows the surgical package definition from CPT2019.
B.
Normal, Uncomplicated Follow-Up (FU)
				Care.
Normal, uncomplicated follow-up (FU) care for the time periods
				indicated in the follow-up days (FUD) column for each procedure code. The
				number in that column establishes the days during which no additional
				reimbursement is allowed for the usual care provided following surgery, absent
				complications or unusual circumstances.
The maximum allowable reimbursement (MAR) covers all normal
				  postoperative care, including the removal of sutures by the surgeon or
				  associate. Follow-up days are specified by procedure. Follow-up days listed are
				  for 0, 10, or 90 days and are listed in the Fee Schedule as 000, 010, or 090.
				  Follow-up days may also be listed as:
MMM indicating that services are for uncomplicated maternity
				  care;
XXX indicating that the global surgery concept does not
				  apply;
YYY indicating that the follow-up period is to be set by the
				  payer (used primarily with BR procedures); or
ZZZ indicating that the code is related to another service
				  and is treated in the global period of the other procedure (used primarily with
				  add-on and exempt from modifier 51 codes).
The day of surgery is day one when counting follow-up days.
				  Hospital discharge day management is considered to be normal, uncomplicated
				  follow-up care.
C.
Follow-up for Diagnostic Procedures.
When a procedure is done for
				diagnostic purposes, the follow-up does not include care of the condition
				itself, only recovery/recovery care for the procedure itself.
D.
Follow-up Care for Therapeutic
				Surgical Procedures.
When a procedure is therapeutic in nature, the
				follow-up care includes routine post-op care and recovery. Any care needed for
				complications, care needed that is not part of routine post-op recovery, or any
				care that is not due to the procedure itself, may warrant additional charges.
E.
Separate Procedures.
Separate procedures are commonly carried out as an integral part of
				another procedure. They should not be billed in conjunction with the related
				procedure. These procedures may be billed when performed independently by
				adding modifier 59 to the specific "separate procedure" code.
F.
Additional Surgical
				Procedure(s).
When an additional surgical procedure(s) is carried out
				within the listed period of follow-up care for a previous surgery, the
				follow-up periods will continue concurrently to their normal terminations.
G.
Microsurgery, Operating
				Microscope, and Use of Code 69990.
The surgical microscope is employed
				when the surgical services are performed using the techniques of microsurgery.
				Code 69990 should be reported (without modifier 51 appended) in addition to the
				code for the primary procedure performed. Do not use 69990 for visualization
				with magnifying loupes or corrected vision.
Do not report 69990 in addition to procedures where use of
				  the operating microscope is an inclusive component (15756-15758, 15842,
				  19364,19368, 20955-20962, 20969-20973, 22551, 22552, 22856-22861, 26551-26554,
				  26556, 31526, 31531, 31536, 31541, 31545, 31546, 31561, 31571, 43116, 43180,
				  43496, 46601, 46607, 49906, 61548, 63075-63078, 64727, 64820-64823, 64912,
				  64913, 65091-68850.)
For purposes of clarification, if microsurgery technique is
				  employed and the primary procedure code is not contained in the list above, it
				  is appropriate to report 69990 with the primary procedure performed and
				  reimbursement is required for such services. (For example, code 63030 is not
				  included in the list therefore, it is appropriate for providers to report 69990
				  along with 63030 to describe microsurgical technique.)
Reimbursement for 69990 is required provided operative
				  documentation affirms microsurgical technique and not just visualization with
				  magnifying loupes or corrected vision
H.
Unique Techniques.
A surgeon
				is not entitled to an extra fee for a unique technique. It is inappropriate to
				use modifier 22 unless the procedure is significantly more difficult than
				indicated by the description of the code.
I.
Surgical Destruction.
Surgical destruction is part of a surgical procedure, and different methods of
				destruction (e.g., laser surgery) are not ordinarily listed separately unless
				the technique substantially alters the standard management of a problem or
				condition. Exceptions under special circumstances are provided for by separate
				code numbers.
J.
Incidental
				Procedure(s).
An additional charge for an incidental procedure (e.g.,
				incidental appendectomy, incidental scar excisions, puncture of ovarian cysts,
				simple lysis of adhesions, simple repair of hiatal hernia, etc.) is not
				customary and does not warrant additional reimbursement.
K.
Endoscopic Procedures.
When
				multiple endoscopic procedures are performed by the same practitioner at a
				single encounter, the major procedure is reimbursed at one hundred percent
				(100%). If a secondary procedure is performed through the same opening/orifice,
				fifty percent (50%) is allowable as a multiple procedure. However, diagnostic
				procedures during the same session and entry site are incidental to the major
				procedure.
L.
Biopsy
				Procedures.
A biopsy of the skin and another surgical procedure
				performed on the same lesion on the same day must be billed as one procedure.
M.
Repair of Nerves, Blood
				Vessels, and Tendons with Wound Repairs.
The repair of nerves, blood
				vessels, and tendons is usually reported under the appropriate system. Normal
				wound repair is considered part of the nerve, blood vessel and/or tendon
				repair. Additional reimbursement for wound repair is only warranted if it is a
				complex wound, and modifier 59 should be used to identify such.
N.
Suture Removal.
Billing for
				suture removal by the operating surgeon is not appropriate as this is
				considered part of the global fee.
O.
Joint Manipulation Under
				Anesthesia.
There is no charge for manipulation of a joint under
				anesthesia when it is preceded or followed by a surgical procedure on that same
				day by that surgeon. However, when manipulation of a joint is the scheduled
				procedure and it indicates additional procedures are necessary and appropriate,
				the lesser of the billed amount or fifty percent (50%) of the MAR for
				manipulation may be allowed.
P.
Supplies and Materials.
provided by the physician (e.g., sterile
				trays/drugs) over and above those usually included with the office visit may be
				listed separately using CPT code 99070 or specific HCPCS codes.
Q.
Aspirations and Injections
Puncture of a cavity or joint for aspiration followed by injection of a
				therapeutic agent is one procedure and should be billed as such. When joint
				injections/trigger point injections are performed, ultrasound and/or Doppler
				guidance is considered integral to the procedure and will not be separately
				reimbursed.
When a joint injection is performed at the end of a surgical
				  procedure for pain control, whether done by the surgeon or by anesthesia,
				  reimbursement is allowed according to the Multiple Procedure Billing rule. This
				  rule applies to facility reimbursement as well as provider
				  reimbursement.
R.
Platelet Rich Plasma (PRP) Injections
The maximum allowable
				reimbursement for PRP injections applies to all body parts and includes imaging
				guidance, harvesting and preparation, as well as the injection, kits and
				supplies.
S.
Surgical
				Assistant
1. Physician Surgical
				Assistant - For the purpose of reimbursement, a physician who assists at
				surgery is reimbursed as a surgical assistant. Assistant surgeons should use
				modifier 80 and are allowed the lesser of the billed amount or twenty percent
				(20%) of the maximum allowable reimbursement (MAR) for the procedure(s).
2. Registered Nurse Surgical
				Assistant or Physician Assistant
a. A
				physician assistant, or registered nurse who has completed an approved first
				assistant training course, may be allowed a fee when assisting a surgeon in the
				operating room (O.R.).
b. The MAR
				for the physician assistant or the registered nurse first assistant (RNFA) is
				ten percent (10%) of the surgeon's fee for the procedure(s) performed.
c. Under no circumstances will a
				fee be allowed for an assistant surgeon and a physician assistant or RNFA at
				the same surgical encounter.
d.
				Registered nurses on staff in the O.R. of a hospital, clinic, or outpatient
				surgery center do not qualify for reimbursement as an RNFA.
e. CPT codes with modifier AS or modifier 81
				should be used to bill for physician assistant or RNFA services on a CMS-1500
				form or electronic claim and should be submitted with the charge for the
				surgeon's services.
3.
				The Fee Schedule includes a column indicating which procedures are approved for
				assistant services with Y (yes) or N (no). If a surgical procedure is
				approved/precertified for a code with a Y in the "Assist Surg" column, the
				assistant is implied and does not require separate approval/pre-certification
				for reimbursement.