Revenue Cycle

CMS issues payment methodology for global surgical split care submitted with Modifier -54 and/or -55 for CAH Method II providers

Medicare Update for CAHs, August 22, 2012

On August 3, CMS issued a transmittal and accompanying MLN Matters article that provides instructions for implementing the payment methodology for global surgical split care submitted with modifier -54 and/or -55 for critical access hospital (CAH) Method II providers.

When global surgical procedures are rendered by a physician or non-physician practitioner billing on a type of bill 85X for professional services in a Method II CAH—thus reassigning their rights to the CAH—it is only payable by Medicare when billed with revenue code (RC) 096x, 97x and/or 98x, and modifier -54 (surgical care only) and/or modifier -55 (postoperative management only).

If more than one physician renders services in the global surgical package, the physician who performs the surgical procedure may not always provide post-operative care. In these cases, payment for the follow-up/post-discharge care is split between two or more physicians where the physicians agree on the transfer of care, according to the transmittal.

In these cases—when more than one physician is involved in the global surgical package—the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services, except where stated policies result in a payment that is higher than the global allowed amount, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care, according to CMS.

If a transfer of care does not occur, the service provided by another physician can be either paid separately or denied for medical necessity reasons, depending on the circumstances, according to CMS, which suggests that providers review the split global surgery pricing rules in the Claims Processing Manual, chapter 1, Sections 40.1-40.5, available here.

With this new guidance, the above payment logic is implemented into the fiscal intermediary shared system (FISS) for CAH Method II providers to mirror the logic historically applied to physician and non-physician practitioners that bill their own services to the Medicare multi-carrier system (MCS). When payments are reduced as a result of this new guidance, Medicare will reflect it on the remittance advice using claim adjustment code 59 (Processed based on the multiple or concurrent procedure rules) and Group Code CO to denote contractual obligation, according to the MLN Matters article.

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