La. Admin. Code tit. 40 § I-5115

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5115 - Surgery Guidelines

A. General Guidelines

1. Global Surgery. 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 before and after surgery. The global reimbursement includes:

a. the initial evaluation or consultation by a surgeon will be paid separately. The pre-operative policy will include all pre-operative visits, in or out the hospital, by the surgeon beginning the day before the surgery;

b. local anesthesia, such as infiltration, digital or topical anesthesia;

c. normal, uncomplicated follow-up care for the time periods indicated in the follow-up days column to the right of 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. Follow-up days are specified by procedures. The day of surgery is day one when counting follow-up days;

d. the global fee will include services such as dressing changes, local incisional care, removal of operative packs, removal of cutaneous sutures, staples, lines, wires, tubes, drains, casts and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines nasogastric and rectal tubes, and change and removal of tracheostomy tubes.

2. Follow-Up Care for Diagnostic Procedures. Follow-up care for diagnostic procedures, e.g., endoscopy, arthroscopy, injections procedures for radiography; includes only care that is related to the recovery from the diagnostic procedure itself. Care of the condition for which the diagnostic procedure was performed or of other concomitant condition is not included and may be charged for in accordance with the services provided.

3. Follow-Up Care for Therapeutic Surgical Procedures. Follow-up care for therapeutic surgical procedures includes only care that is usually part of the surgical procedure. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services concurrent with the procedure(s) or during the listed period of normal follow-up care may warrant additional charges. The workers' compensation carrier is responsible only for charges related to the compensable injury or illness unless the noncompensable condition has a direct bearing on the treatment of the compensable condition.

4. 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 other normal terminations.

5. Operating Microscope. Additional reimbursement for the use of an operating microscope (excluding loupes or other magnifying devices) will be allowed when the listed code does not state the use of the microscope is inherent in the procedure.

6. 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.

7. Surgical Destruction. Surgical destruction is part of a surgical procedure, and different methods of destruction 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.

8. 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.

9. Endoscopic Procedures. When multiple endoscopic procedures are performed, the major procedure is reimbursed at 100 percent. If a secondary procedure is performed through the same opening/orifice, 50 percent is allowable as a multiple procedure. However, diagnostic procedures during the same session and entry site are incidental to the major procedure, which is coded per the deepest penetration. Generally, no payment will be made for a visit on the same day in addition to the endoscopic procedure unless documented, separately identifiable service is furnished.

10. 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.

11. 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. The repair of associated wounds is included in the primary procedure unless it qualifies as a complex wound, in which case Modifier-51 may be applied. Simple exploration of nerves, blood vessels, and tendons exposed in an open wound is also considered part of the essential treatment of the wound closure and is not a separate procedure unless appreciable dissection is required.

12. Suture Removal. Billing for suture removal by the operating surgeon is not appropriate as this is considered part of the global fee.

13. 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 or associate. However, when manipulation of a joint is the scheduled procedure and it indicates additional procedures are necessary and appropriate, 50 percent of the manipulation may be allowed.

14. Supplies and Materials. 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. These supplies and materials over $50 will be reimbursed at invoice cost plus 20 percent. Specialized supplies and DME may require a copy of the invoice be sent to the C/SIE.

15. Plastic and Metallic Implants. Plastic and metallic implants or non-autogenous graft materials supplied by the physician are to be reimbursed at invoice cost plus 20 percent. An invoice with the cost of the material must be submitted to the C/SIE with the bill.

16. Aspirations and Injections. Puncture of a cavity of joint for aspiration followed by an injection of a therapeutic agent is one procedure and should be billed as such.

17. Assistant-at-Surgery. An assistant-at-surgery is an individual who has the necessary qualifications to participate in a particular operation and actively assist in performing the surgery.

a. A physician who assists at surgery may be reimbursed as a surgical assistant. The surgical assistant must bill separately from the primary physician. Modifier-80 should be used. Reimbursement should be 20 percent of the allowable reimbursement amount for the procedure(s). The assistant surgeon's name should be listed on the operative report.

b. Payment for physician assistant, nurse practitioner or surgical technicians will be made only to the employer not to the individual. Reimbursement is limited to 65 percent of the allowable amount for M.D. assistant surgeons.

c. Reimbursement for assistants at surgery shall be based on medical necessity. If a procedure usually does not require the use of an assistant, documentation of medical necessity shall be submitted with the claim form.

18. Operative Reports. An operative report must be submitted to the carrier before reimbursement can be made for the surgeon's or assistant surgeon's services.

19. Needle Procedures. Needle procedures (lumbar puncture, thoracentesis, jugular or femoral taps, etc.) should be billed in addition to the medical care on the same day.

20. Therapeutic Procedures. Therapeutic procedures (injecting into cavities, nerve blocks, etc.) (20550-20610; 64400-64450) may be billed in addition to the medical care for a new patient. (Use appropriate level of service plus injection.) In follow-up cases for additional therapeutic injections and/or aspirations, an office visit is only indicated if it is necessary to re-evaluate the patient. In this case, a minimal visit may be listed in addition to the injection. Documentation supporting the office visit charge must be submitted with the bill to the carrier/SIE. Reimbursement for therapeutic injections will be made according to the multiple procedure rule. Trigger point injection is considered one procedure and reimbursed as such regardless of the number of injection sites.

21. Anesthesia by Surgeon. In certain circumstances it may be appropriate for the attending surgeon to provide regional or general anesthesia. Anesthesia by the surgeon is considered to be more than local or digital anesthesia. Identify this service by adding the Modifier-47 to the surgical code. Only base anesthesia units are allowed (See Anesthesia, §5117).

B. Multiple Procedures

1. Multiple Procedure Reimbursement Rule. When more than one procedure is performed during the same operative session at the same operative site and also multiple procedures performed during the same operative session through multiple incisions for the same operative procedure the following reimbursement applies:

a. 100 percent for the primary procedure;

b. 60 percent for the second procedure;

c. 40 percent for the third procedure;

d. 25 percent for fourth and fifth procedures; and

e. each procedure after the fifth procedure will be paid by special report.

2. Bilateral Procedure Reimbursement Rule. When bilateral procedures are performed that require preparation of separate operative sites, e.g., bilateral carpal tunnel, the second (or bilateral) site will be reimbursed as follows:

a. 75 percent value for the primary procedure at the remote site;

b. 60 percent for the second procedure at the remote site;

c. 40 percent for the third procedure at the remote site; and

d. 25 percent for fourth and fifth procedures at the remote site.

3. Multiple Procedure Reimbursement. When multiple surgical procedures are performed in different areas of the body during the same operative sessions and the procedures are unrelated (i.e., abdominal hernia repair and a knee arthroscopy), the multiple procedure reimbursement rule will apply independently to each area. Modifier-51 must be added.

C. Burns, Local Treatment

1. Degree of Burns

a. Code 16000 must be used when billing for treatment of first degree burns when no more than local treatment of burned surfaces is required.

b. Codes 16010-16030 must be used when billing for treatment of second and third degree burns only.

c. The claim form must be accompanied by a report substantiating the services performed.

d. Major debridement of foreign bodies, grease, epidermis, or necrotic tissue may be billed separately under Codes 11000-11001. Modifier-51 does not apply.

e. In order to identify accurately the proper procedure code and substantiate the descriptor for billing, the exact percentage of the body surface involved and the degree of the burn must be specified on the claim form submitted or by attaching a special report.

f. The following definitions apply to Codes 16010-16030.

Small- less than 9 percent of the body area.

Medium- 9-18 percent of the body area.

Large- greater than 18 percent of the body area.

g. Claims submitted without specification of the degree of burn and exact percentage of body area involved must be returned to the physician for this additional information.

h. Hospital visits, emergency room visits, or critical care visits provided by the same physician on the same day as the application of burn dressings will be reimbursed as a single procedure at the highest level of service, except in case of an asterisk.

D. Nerve Blocks

1. Diagnostic or Therapeutic

a. When a nerve block is performed for diagnostic or therapeutic purposes, the appropriate procedure code must be billed (62274-62279 or 64400-64530). It is inappropriate to use base and/or time units even when performed by an anesthesiologist.

b. Medications such as steroid, pain medication, etc., may be separately billed using Code 99070.

i. The name of the medication(s), dosage, and volume must be identified.

ii. Medication will be reimbursed at a reasonable cost.

2. Anesthetic

a. When a nerve block for anesthesia is provided by the operating room surgeon, the procedure codes listed in §5117, Anesthesia, must be followed.

E. Surgery Modifiers

1. Modifier codes may be used by providers to identify procedures or services that are modified due to specific circumstances.

2. Modifiers listed in the CPT must be added to the procedure code when the service or procedure has been altered from the basic procedure described by the descriptor.

3. When Modifier-22 is used to report an unusual service, a report explaining the medical necessity of the situation must be submitted with the claim to the C/SIE. It is not appropriate to use Modifier-22 for routine billing.

4. The use of modifiers does not imply or guarantee that a provider will receive reimbursement as billed. Reimbursement for modified services or procedures must be based on documentation of medical necessity and must be determined on a case by case basis.

F. Starred Procedures (starred in CPT book). Certain small surgical services involve a readily identifiable surgical procedure but include variable pre- and post-operative services (e.g., incision and drainage of an abscess, injection of a tendon sheath, manipulation of a joint under anesthesia). Because of the indefinite pre- and post-operative services, the usual "package" concept of surgical services cannot be applied. These procedures are identified in the CPT by a star (*) following the procedure code number.

La. Admin. Code tit. 40, § I-5115

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.