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MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit MO HealthNet Division ASSISTANT SURGEONS AND RELATED POST-OPERATIVE CARE Presented by the Provider Education Unit MO HealthNet Division

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Presentation Transcript
slide1
MO HealthNet Internet Provider

Training Program

Presented by the Provider Education Unit

MO HealthNet Division

MO HealthNet Division

assistant surgeons and related post operative care
ASSISTANT SURGEONS AND RELATED POST-OPERATIVE CARE

Presented by the Provider Education Unit

MO HealthNet Division

MO HealthNet Division

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Information regarding assistant surgeons can be found in Section 13.41 of the Physician Provider Manual. To access the manual go to the MHD Public Web site:

www.dss.mo.gov/mhd/providers/index.htm.

In the left hand column, scroll down and click on Provider Manuals.

MO HealthNet Division

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The services of an assistant surgeon are

billed with modifier 80.

Only one assistant surgeon can be paid for those procedures that warrant an assistant.

An assistant surgeon’s fee is reimbursable at 20% of the surgeon’s fee for the surgical procedure.

MO HealthNet Division

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The services of an assistant surgeon are

billed with modifier 80.

Only one assistant surgeon can be paid for those procedures that warrant an assistant.

An assistant surgeon’s fee is reimbursable at 20% of the surgeon’s fee for the surgical procedure.

MO HealthNet Division

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The services of an assistant surgeon are

billed with modifier 80.

Only one assistant surgeon can be paid for those procedures that warrant an assistant.

An assistant surgeon’s fee is reimbursable at 20% of the surgeon’s fee for the surgical procedure.

MO HealthNet Division

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If the surgeon’s claim is systematically priced, the assistant surgeon’s claim is also systematically priced.

If the surgeon’s claim is manually priced, the assistant surgeon’s claim is also manually priced, and an operative report must be attached to the paper claim for payment.

MO HealthNet Division

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If the surgeon’s claim is systematically priced, the assistant surgeon’s claim is also systemically priced.

If the surgeon’s claim is manually priced, the assistant surgeon’s claim is also manually priced, and an operative report must be attached to the paper claim for reimbursement.

MO HealthNet Division

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MO HealthNet does not reimburse for the

services of an assistant surgeon when a co-

surgeon is used.

MO HealthNet Division

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Registered nurses and other non-physician personnel are ancillary staff and not considered “assistant surgeons” or “assistants at surgery”and services performed by them are, therefore, not billable to MO HealthNet as a separate service.

MO HealthNet Division

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Follow-up care provided by the assistant surgeon is subject to the 30-day postoperative policy as described in Section 13.41 of the Physician Manual.

MO HealthNet Division

postoperative care
Postoperative Care

Postoperative care includes 30 days of routine follow-up for those surgical or diagnostic procedures having a MO HealthNet reimbursement amount of $75.00 or more. For counting purposes, the date of surgery is the first day.

MO HealthNet Division

postoperative care continued
Postoperative Care (continued)

This policy applies whether the procedure was performed in the hospital, ambulatory surgical center or an office setting, and applies to subsequent physician visits.

Pain management is considered part of postoperative care. Visits for the purpose of postoperative pain control are not separately reimbursable.

MO HealthNet Division

postoperative care continued14
Postoperative Care (continued)

This policy applies whether the procedure was performed in the hospital, ambulatory surgical center or an office setting, and applies to subsequent physician visits.

Pain management is considered part of postoperative care. Visits for the purpose of postoperative pain control are not separately reimbursable.

MO HealthNet Division

postoperative care continued15
Postoperative Care (continued)

Supplies necessary for providing the follow-up care in the office, such as splints, casts and surgical dressings in connection with covered surgical procedures that meet the postoperative care policy, may be billed under the appropriate supply code. Attach an invoice if applicable.

MO HealthNet Division

exceptions to post operative care
Exceptions to Post-operative Care
  • Services that are exceptions to the postoperative care policy may be reimbursed for complications or extenuating circumstances that have been documented and determined to be exempt by the state medical consultant.
  • In addition, the following services are exempt from the postoperative policy limitations:

MO HealthNet Division

exceptions to post operative care continued
Exceptions to Post-operative Care (continued)
  • Exceptions to the postoperative care policy may be reimbursed for complications or extenuating circumstances that have been documented and determined to be exempt by the state medical consultant.
  • In addition, the following services are exempt from the postoperative policy limitations:

MO HealthNet Division

exceptions to post operative care continued18
Exceptions to Post-operative Care (continued)
  • Initial hospital visits to allow payment for physician services when a patient is admitted to the hospital on the same day of service as a surgery.
  • Consultations
  • Renal dialysis codes.
  • Physician services provided prior to the date of surgery.

MO HealthNet Division

exceptions to post operative care continued19
Exceptions to Post-operative Care (continued)
  • Initial Hospital visits to allow payment for physician services when a patient is admitted to the hospital on the same day of service as a surgery.
  • Consultations.
  • Renal dialysis codes.
  • Physician services provided prior to the date of surgery.

MO HealthNet Division

exceptions to post operative care continued20
Exceptions to Post-operative Care (continued)
  • Initial Hospital visits to allow payment for physician services when a patient is admitted to the hospital on the same day of service as a surgery.
  • Consultations.
  • Renal dialysis codes.
  • Physician services provided prior to the date of surgery.

MO HealthNet Division

exceptions to post operative care continued21
Exceptions to Post-operative Care (continued)
  • Initial Hospital visits to allow payment for physician services when a patient is admitted to the hospital on the same day of service as a surgery.
  • Consultations.
  • Renal dialysis codes.
  • Physician services provided prior to the date of surgery.

MO HealthNet Division

exceptions to post operative care continued22
Exceptions to Post-operative Care (continued)
  • All surgeries or procedures billed having a reimbursement amount of less than $75.00.
  • Newborn care.
  • Suture removal.

MO HealthNet Division

exceptions to post operative care continued23
Exceptions to Post-operative Care (continued)
  • All surgeries or procedures billed having a reimbursement amount of less than $75.00.
  • Newborn care.
  • Suture removal.

MO HealthNet Division

exceptions to post operative care continued24
Exceptions to Post-operative Care (continued)
  • All surgeries or procedures billed having a reimbursement amount of less than $75.00.
  • Newborn care.
  • Suture removal.

MO HealthNet Division

slide25

The surgeon and assistant surgeon must each submit separate professional claims for services provided, using his/her individual NPI.

A clinic may submit a single professional claim using the clinic’s NPI and must indicate each individual provider’s NPI as the performing provider.

MO HealthNet Division

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The surgeon and assistant surgeon must each submit separate professional claims for services provided, using his/her individual NPI.

A clinic may submit a single professional claim using the clinic’s NPI and must indicate each individual provider’s NPI as the performing provider.

MO HealthNet Division

slide27

For assisting at cesarean deliveries, the appropriate CPT procedure code for instance, procedure code 59514, for the delivery only must be billed, regardless of whether or not the surgeon billed the global procedure. A “Global” delivery indicates that the prenatal care, delivery and postpartum care are provided by a single physician or private medical clinic/group.

MO HealthNet Division

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Thank you again for participatingin this training session. If you have questions regarding the information in this presentation, please contact the Provider Education Unit at 573-751-6683.

MO HealthNet Division

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