Policy will apply to all professional services performed in an office place of service, when significant, separately identifiable E/M service (appended with 25 modifier) and any service that has a global period indicator as designated by CMS of 0, 10, 90 or YYY is performed on the same day, E&M service will be reimbursed at 50% of the contracted allowable. When the E&M value is greater than the procedure, the reduction will be applied to the global procedure code.
Harvard Pilgrim reimburses only the most intensive CPT code when:
• A procedure is considered to be normally included as part of a more comprehensive code.
• A single, more comprehensive CPT code more accurately describes a group of procedures.
• If a procedure that is generally carried out as an integral part of a larger surgical procedure is performed alone and independent of other surgical services, it is reimbursable.
• When multiple procedures are performed at the same session, the primary procedure is reimbursed at 100% of the allowable rate and all subsequent reimbursable procedures are paid at 50% of the allowable rate.
• Harvard Pilgrim determines the primary procedure based on the highest allowable rate, not the charge.
• Bilateral surgeries are reimbursed at 150% of the allowable rate.
• Bilateral assistant surgeons are reimbursed at 16% of the allowable 150% amount.
Professional, Multiple and Bilateral Surgery Services Performed During the Same Operative Session
When a bilateral procedure code and surgical procedure(s) are performed at the same session and eligible for multiple procedure reduction, claim will be subject to multiple procedure reduction and bilateral procedure payment adjustment in accordance with Harvard Pilgrim payment policy. If the bilateral procedure is the secondary procedure, multiple procedure reduction and bilateral procedure payment adjustment will be applied.
• Add-on codes are reimbursed at 100% of the allowable rate and are not subject to the multiple procedure reduction.
• Add-on codes are only those codes designated by CPT and identified by a specific descriptor that includes the phrase
“each additional” or “list separately in addition to the primary procedure.”
• Add-on codes are reimbursable only when billed with their primary procedure.
Cosmetic surgery is reimbursable with prior authorization of any cosmetic surgery exceptions, including, but not limited to:
• Repair of an accidental injury (e.g., repair of the face following a serious automobile accident).
• Improved function of a malformed body part.
• Treatment of severe burns.
• For additional information, refer to the Cosmetic, Reconstructive and Restorative Procedures Payment Policy.
E&M services provided within global period
Based on the CMS global surgical period:
• FCHP does not separately reimburse for any E&M service when reported with major surgical procedures (90-day global surgical period)
• FCHP does not separately reimburse for any E&M service when reported with minor procedures with a 10-day post-op period.
• FCHP does separately reimburse for new patient E&M services and E&M services described in Proceure as applying to new or established patients when reported with minor procedures with a 0-day post-op period.
• FCHP does consider reimbursement for services rendered during the global period if the appropriate modifier -24 is appended to the E&M procedure code and medical notes are included.
Services rendered in the office after-hours or on weekends or holidays
• FCHP reimburses Proceure Code 99050 for services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday), in addition to basic service.
• FCHP reimburses Proceure Code 99051 for services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.