20 Miss. Code. R. 2-I

Current through October 31, 2024

Section 20-2-I - GENERAL GUIDELINES

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.

T.Operative Reports. An operative report must be submitted to the payer before reimbursement can be made for the surgeon's or assistant surgeon's services, and should document the use of assistant services.

U.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.

V.Therapeutic Procedures. Therapeutic procedures (injecting into cavities, nerve blocks, etc.) (CPT codes 20526-20611, 64400-64450, 64455-64484) 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 payer.

Reimbursement for therapeutic injections will be made according to the multiple procedure rules.

Trigger point injection is considered one procedure and reimbursed as such regardless of the number of injection sites. Two codes are available for reporting trigger point injections. Use 20552 for injection(s) of single or multiple trigger point(s) in one or two muscles or 20553 when three or more muscles are involved.

W.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 modifier 47 to the surgical code. Only base anesthesia units are allowed. See the Anesthesia section.

XTherapeutic/Diagnostic Injections. Injections are considered incidental to the procedure when performed with a related invasive procedure.

YIntervertebral Biomechanical Device(s). CPT codes 22853, 22854 and 22859 describe the insertion of an intervertebral biomechanical device into an interverbral disc space or vertebral body defect. These codes are reported per level; each code captures insertion of both devices with integral anterior instrumentation for device anchoring and devices without integral anterior instrumentation for device anchoring, regardless of approach (anterior, posterior, lateral). Coding is based on the location of the device insertion and whether interbody arthrodesis is being performed.

ZIntra-operative Neurophysiologic Monitoring (e.g., SSEP, MEP, BAEP, TES, DEP, VEP) Reimbursement for intra-operative neurophysiologic monitoring will not be allowed in the following cases, unless pre-certification is obtained from the payer prior to the services.:

1. Neuromuscular junction testing of each nerve during intraoperative monitoring;

2. Intraoperative monitoring during peripheral nerve entrapment releases, such as carpal release, ulnar nerve transposition at the elbow, and tarsal tunnel release;

3. During decompression of cervical nerve roots without myelopathy;

4. During placement of cervical instrumentation absent evidence of myelopathy;

5. During lumbar discectomy for radiculopathy; or

6. During lumbar decompression for treatment of stenosis without the need for instrumentation.

20 Miss. Code. R. 2-I

Amended 6/14/2017

Amended 6/15/2019