Chapter 4.5. Division of Workers' Compensation
SUBCHAPTER 1. ADMINISTRATIVE DIRECTOR -ADMINISTRATIVE RULES
Article 5.3. Official Medical Fee Schedule

§9789.16.3. Surgery - Global Fee - Miscellaneous Rules.

(a) Relationship to Correct Coding Initiative (CCI)

The CCI edits allow the claims administrator to detect instances of fragmented billing for certain intra-operative services and other services furnished on the same day as the surgery that are considered to be components of the surgical procedure and, therefore, included in the global surgical fee. When both correct coding and global surgery edits apply to the same claim, the claims administrator shall first apply the correct coding edits, then, apply the global surgery edits to the correctly coded services.

(b) Claims From Physicians Who Furnish Less Than the Global Package (Split Global Care)

(1) For surgeries that are billed with either modifier “-54” or “-55,” the claims administrator shall pay the applicable percentage of the fee schedule payment. Columns labeled “Pre Op”, “Intra Op” and “Post Op” of the National Physician Fee Schedule Relative Value File, list the 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.

(2) Where more than one physician bills for the postoperative care, the claims administrator will apportion the postoperative percentage according to the number of days each physician was responsible for the patient's 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

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 fee 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. Smith's 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).

(3) Procedures with a “000” entry in “Glob Days” column have an entry of “0.0000” in the Pre Op, Intra Op and Post Op columns. Split global care does not apply to these procedures.

(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, the claims administrator shall pay the value of the intra-operative services of the code that describes the treatment of the complications. Refer to the Intra Op column of the National Physician Fee Schedule Relative Value File to determine the percentage of the global package for the intra-operative services. The fee schedule amount 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, the claims administrator shall pay the full value for the procedure, since these codes have no pre-, post-, or intra-operative values.

When an unlisted procedure is billed because no code exists to describe the treatment for complications, the claims administrator shall base payment on a maximum of 50 percent of the value of the intra-operative services originally performed. If multiple surgeries were originally performed, the claims administrator shall base payment on no more than 50 percent of the value of the intra-operative services of the surgery for which the complications occurred. The claims administrator shall multiply the fee schedule amount for the original surgery by the intra-operative percentage for the procedure, 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, the claims administrator shall pay the additional procedures as multiple surgeries. Only surgeries that require 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 complications 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.

Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.

HISTORY

1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).