Section 5: Surgery

Note: Please see the ADDENDUM at the end of this document.

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General Information

LISTED VALUES

The values listed for all surgical procedures include the surgery, local infiltration, digital block, or topical anesthesia when used.

BR (BY REPORT)

When the value of a procedure is to be determined by BY REPORT (BR) a copy of the hospital operative report (or similar office record in non-hospital cases), it will be necessary to substantiate the charges.

SUPPLIES AND MATERIALS

Supplies and materials supplied by the physician (e.g., sterile trays, drugs, etc.) over and beyond those usually included with the office visit or other services rendered may be charged for separately.

MULTIPLE SURGERY PROCEDURES PERFORMED

• Independent multiple or bilateral surgical procedures performed by separate surgical teams at the same operative session are usually separately charged.
  
• Multiple or bilateral surgical procedures which add time or complexity to patient care, are performed independently at the same operative session by the same surgeon, are usually charged separately with due consideration being given to the separate value of these services.
  
• Multiple surgical procedures performed through the same incision will have the unit value of the major procedure only – unless complicated and requiring extensive time, when individual consideration will be given. (See Addendum)
  
• Multiple operative procedures performed at the same session in separate operative fields and through separate incisions are usually charged at the total value of the major procedure, allowing 50 percent (50%) of the value of the lesser procedure. (See Addendum)

CASTING

The values for procedures include the application and removal of the first cast or traction device only. Subsequent replacement of case and/or traction device warrants an additional charge.

RE-REDUCTION OF FRACTURES

Rereduction of a fracture and/or dislocation, performed as a separate procedure by the primary physician, may warrant an added charge for this secondary service.

BONE OR TISSUE GRAFTS

Bone or other tissue grafts obtained at a distance from the surgical field warrant an added charge if it is not a part of the procedure description. Plastic and metallic implant or non-autogenous graft materials supplied by the physician are to be valued at the cost of the physician.

TWO OR MORE PHYSICIANS REQUIRED

When warranted by the necessity of supplemental skills, values for services rendered by two or more physicians will be allowed at BR substantiated by a written report. (See Addendum regarding modifier 62)

UNUSUAL SERVICES

Complicated procedures or other circumstances which require unusual service and extensive follow up care will be allowed at BR substantiated by a written report.

ASSISTANT SURGERY

Surgical assistant services are valued at twenty percent (20%) of the listed value of surgical procedure(s) in complicated cases. Please refer to the list of surgical procedures which normally require an assistant surgeon. (See Addendum regarding physician assistants)

PROCEDURES WITHOUT UNIT VALUES

Procedures listed as BY REPORT (BR) are variable in time, skill, complexity, et cetera, and no fixed value can be assigned. When the value of a procedure is to be determined by BR, a copy of the hospital operative report, similar office records, or information to substantiate the charge should be submitted.

SPECIAL CONSIDERATION

Anyone who feels he/she has special qualifications not adequately compensated by this schedule should make an appeal to the North Carolina Industrial Commission for special consideration.

SURGERY PROCEDURES INTEGUMENTARY SYSTEM REPAIR

The repair of wounds may be classified as Simple, Intermediate, or Complex.

Simple Repair is used when the wound is superficial; i.e., involving skin and/or subcutaneous tissues, without significant involvement of deeper structures and adhesive strips. List appropriate visit only.

Intermediate Repair includes repair of wounds that, in addition to the above, require layer closure. Such wounds usually involve deeper layers, such as fascia or muscle, to the extent that at least one of the deeper layers requires separate closure.

Complex Repair includes the repair of wounds requiring reconstructive surgery, complicated wound closures, skin grafts, or unusual and time-consuming techniques of repair to obtain the maximum functional and cosmetic result. It may include creation of the defect and necessary preparation for repairs of the debridement and repair of complicated lacerations or avulsions.

Suture Removal by the same physician or an associate will be included in the charge for the original procedure.

Follow-up Days for procedures in the Fee Schedule indicating follow-up days include the charges for the office and hospital visits for those lengths of days.   There is no charge allowed for the office and hospital visits during this time period. You may, however, charge for any supplies, etc., that you furnish from your office. If the length of follow-up care goes beyond the number of follow-up days indicated, the physician will be allowed to begin charging for office or hospital visits again.

GENERAL INFORMATION AND GROUND RULES

1. Arthroscopy. (See Addendum)
   
2. Spinal Instrumentation. (See Addendum)
   
3. Diskectomy. (See Addendum)
   
4. Microsurgery. The Commission does not allow for the use of a microscope for surgery unless it is a surgery on nerves or blood vessels. A special report may be appropriate to document the necessity of the microsurgical approach (CPT codes 64727 and 69990). (See Addendum)
   
5. Bilateral Procedures. When billing for bilateral procedures, use CPT code for surgery, with a modifier –50 listed beside the code. The Commission will allow 50 percent (50%) more for bilateral surgeries. (See Addendum)
   
6. No Allowance. No allowance will be made for acupuncture, “no shows,” or cancelled surgeries. (See Addendum in the Evaluation and Management Section)

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ADDENDUM

Surgery Fees and Proper Guidelines for Applying the Global Period

Former Chief Medical Fee Examiner Jennifer Gudac's June 21, 2002 memo specifies Surgery Fees and Proper Guidelines for Applying the Global Period.

Three Revisions Effective March 1, 2001

1. REVISION IN THE REIMBURSEMENT METHODOLOGY FOR PHYSICIAN ASSISTANTS PERFORMING THE SERVICES OF A MINIMUM SURGICAL ASSISTANT

The North Carolina Industrial Commission will allow reimbursement of physician assistant services, when assisting in surgery, as a minimal surgical assistant at the rate of seventeen percent (17%) of the fee schedule allowance.

The seventeen percent (17%) is based on eighty-five percent (85%) of the assistant surgeon’s fee of 20 percent (20%). This rate would equal the same as that applied by the Health Care Finance Administration (HCFA).

The surgical procedure code should include modifier 81 (used to identify a minimum assistant surgeon). The name of the physician assistant should appear in Field 31 of the HCFA Form 1500.

2. REVISION IN THE REIMBURSEMENT METHODOLOGY FOR PHYSICIAN ASSISTANTS PERFORMING EVALUATION AND TREATMENT SERVICES IN AN OFFICE, CLINIC OR FACILITY SETTING

The North Carolina Industrial Commission will allow reimbursement of evaluation and treatment services performed by a physician assistant that are considered within the physician assistants’ scope of practice. These services will be reimbursed at the rate of one hundred percent (100%) of the fee schedule allowance. Reimbursement will be allowed regardless of whether a supervising physician is on site at the office, clinic or facility or other place of treatment.

3. REVISION IN THE REIMBURSEMENT METHODOLOGY FOR MULTIPLE ARTHROSCOPIC SURGICAL PROCEDURES PERFORMED DURING THE SAME OPERATIVE SESSION

The North Carolina Industrial Commission will allow reimbursement for multiple arthroscopic procedures at the rates of one hundred percent (100%) for the primary procedure and fifty percent (50%) for each secondary procedure as long as the secondary procedure or procedures are not considered integral to the primary procedure.

The Industrial Commission will utilize appropriate guidelines, namely those issued by the Health Care Financing Administration, in determining reimbursement for multiple arthroscopic procedures.

• Assistant Surgeon Guide—Please correct the Assistant Surgeon Guide accordingly. Because of the variablility in unlisted procedures, each surgery needs to be evaluated to determine if an assistant surgeon is necessary. Therefore the "Y" for CPT code 27599 should be removed. Use of an assistant surgeon for procedures coded with 27599 should be approved based on the complexity of the services provided.

• If an "80", "81", or "82" modifier is used by an assistant surgeon, reimbursement for a licensed physician will be twenty percent of the Fee Schedule allowance. If a physician assistant acts as the assistant surgeon, the modifier "81" should be used with a reimbursement of 17% of fee schedule rate.

• If a physician assistant sees a patient in a physician's office and the physician signs off on the record, the Commission will allow the charge. These services will be reimbursed at the rate of one hundred percent (100%) of the fee schedule allowance. Reimbursement will be allowed regardless of whether a supervising physician is on site at the office, clinic or facility or other place of treatment.

• Regarding multiple surgeries performed during the same operative session, the following Fee Schedule corrections are applicable:

1. Correct paragraph three (3) in the SURGERY Section on page 2 to read:

Multiple surgical procedures performed through the same incision will have the unit value of the major procedure. The secondary or lesser procedure(s) or service(s) may be identified by adding modifier -51 to the secondary procedure. You will be allowed 50% for the additional procedures based on the Medical Fee Schedule allowance.

2. Correct paragraph four (4) in the SURGERY Section on page 2 to read:

Multiple operative procedures performed at the same session in separate operative fields and through separate incisions are allowed total Medical Fee Schedule value for each procedure.

• If surgery is performed, the Medical Fee Schedule states the number of days for which follow-up care is covered under the global surgery package. Reimbursement for routine follow-up hospital/office visits performed within the global period are inclusive of the surgery charge. Providers may use CPT code 99024 for documentation these services. Billing for necessary supplies and medications is allowed within the global period.
   
• All postoperative care is added on a service-by-service basis (eg. Office or hospital visit, case change). Complications are added on a service-by-service basis (as will all surgical procedures).

• Reimbursement for CPT Code 64450 should only be allowed when performed independently from other surgical procedures. If 64450 is billed in conjunction with a starred surgical procedure, then reimbursement for 64450 may be allowed.

• Use of modifier 62 indicates co-surgery. If the physician billing does not indicate the split of fees, then split the fees equally. If no assistant surgeon is involved, allow 60% of the allowed procedure fee for each surgeon. If an assistant surgeon is utilized, allow the primary co-surgeons 50% of the allowed fee.

• No allowance is made for codes 64727 or 61712 (Microsurgery).

• Modifier "20" is for use of the microscope. We allow twenty percent (20%) for this code on surgery for nerve or vessel repair. Likewise, code 69990 should only be allowed for nerve and vessel repair. Do not use 69990 for visualization with magnifying loupes or corrected vision. Do not report code 69990 in addition to procedures where use of the operating microscope is an inclusive component (15756-15758, 19364, 19368, 20955-20962, 20969-20973, 26551-26554, 26556, 31526, 31531, 31536, 31541, 31561, 31571, 43116, 43496, 49906, 61548, 63075-63078, 64727, 65091-68850).

• Modifier "22" is seldom allowed, and then only if the surgery was complicated. If the surgery was complicated, the Commission will allow an additional twenty percent (20%) of the fee schedule reimbursement.

• Procedure codes 62290 and 62291 are modifier 51 exempt in workers’ compensation cases. Each injection procedure for diskography should be reimbursed at full Fee Schedule fee.

• Bilateral Procedures—When billing for bilateral procedures use the CPT code for surgery with a modifier "50" and the Commission will allow fifty percent (50%) more for the codes. Below are examples of such codes.

Example: 63050-50 = 150% x fee schedule allowance for CPT code 63050

• When Trigger Point injections are performed on the same day, allow full fee for first injection, fifty percent (50%) for the second, and twenty-five percent (25%) for the remaining procedures. The medical fee allowed for this procedure(s) should cover the cost of the procedure as well as the cost of medications.

• CPT Codes 20600, 20605, and 20610 should be allowed full fee for each procedure if performed in separate surgical fields; if in same surgical field, allow full fee for first fifty percent (50%) for the second, and twenty-five percent (25%) for the remaining procedures. The medical fee allowed for these procedures covers the cost of the procedure(s). Additionally, medication used in these procedures may be billed at our fee schedule standard of no more than twenty per cent above invoice cost. A copy of invoice may be required by the payer.

• CPT Code 36415 (Routine Venipuncture) should be allowed in addition to office visit if the physician charges a fee.

• The N.C. Industrial Commission Liaison Committee met on March 13, 1997 in Durham, NC, and discussed the Spinal Cord Stimulator. The Food and Drug Administration (FDA) has approved this procedure; therefore; it is the Commission’s position that this procedure is acceptable, providing the Medical Provider feels the procedure will benefit the injured employee. (G.S. §97-25). The Committee and the N.C. Industrial Commission feel this procedure should be reviewed on a case-by-case basis by the Insurance Companies and the Medical Providers.

• Changes in allowance for Diskectomy and additional spaces, when performed in conjunction with a fusion, will be changed effective June 1, 1997. Surgeries rendered on June 1, 1997 and thereafter will be approved as follows:

1. Allow full fee for fusion and additional space. (CPT Codes 22554 and 22585).

2. Allow fifty percent (50%) for Diskectomy (CPT Codes 63075 and 63076).

• Effective October 1, 1998, the Commission will allow charges for spinal instrumentation when done in association with spinal arthrodesis. These codes will not require a modifier 51, but will be allowed in full, in accordance with the Medical Fee Schedule. All surgeries performed on October 1, 1998 and thereafter should be approved by the enclosed fees.

CPT only Copyright ©2004 American Medical Association. All Rights Reserved.

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