General Surgery Coding Alert

The HCFA 2001 fee schedule contains not only information you might expect, such as the number of relative value units (RVUs) assigned to particular procedures or services, but also additional information that can help general surgeons and their coders with coding decisions.

Most people dont realize the HCFA fee schedule can tell you whether you can bill for supplies, or if a procedure allows co-surgery, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. But the fee schedule contains this information and much more, she notes.

The January General Surgery Coding Alert explained how to download and use the 2001 schedule. This final installment will reveal additional information that can be found in the fee schedule, including the level of physician supervision required for a procedure, if multiple surgery guidelines apply, the base endoscopic code for multiple endoscopic procedures, which supplies used to perform a particular procedure can be separately billed, whether modifier -50 (bilateral procedure) can be appended to a service, and whether a co-surgeon or assistant surgeon can be reimbursed for a particular procedure.

Multiple Procedures and Multiple Endoscopies

Column V of the fee schedule indicates how a procedure should be paid if it is not the primary procedure performed during the operative session. Most surgical procedures will have an indicator of 2, designating that the standard multiple procedure payment rule (100 percent for the highest-paying procedure, 50 percent for all the others) applies. (See sample fee schedule included with this issue). Diagnostic tests, such as x-rays, usually include an indicator of 0, meaning that no payment adjustment is made and the service is paid at 100 percent, even if it was performed at the same time as another service. If a procedure has a 1 indicator, it should be paid using the multiple procedure rule in effect before January 1995, which stipulated that procedures were paid at 100 percent/50 percent/25 percent/25 percent, etc. A 9 indicator means that the concept of multiple surgery does not apply.

Endoscopic procedures with a 3 in column V are subject to the multiple endoscopy rule. For example, in the included sample schedule, the endoscopic base code for 45382 (colonoscopy, flexible, proximal to splenic flexure; with control of bleeding, any method) is 45378 (colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]). The 3 in column V indicates that 45382 is subject to the multiple endoscopy rule and has an endoscopic base code.

The endoscopic base code is not included in column V, however. If column V contains a 3, coders should look to column AC, which identifies the base code. In this case, column AC identifies 45378 as the endoscopic base code.

Because it is already a base code, however, 45378 although an endoscopic procedure does not have a base code of its own. Therefore, it shows a 2 in column V and no code appears in column AC.

Note: The multiple endoscopy rule stipulates that if more than one endoscopy with the same base code is performed, the less-valued procedure is paid with the value of the base code subtracted from it. In other words, if a surgeon performs 45382 and 45383 (colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) in his or her own facility, the higher-paid procedure (45383, 13.62 RVUs), would be paid at 100 percent; however, 45382 (13.52 RVUs) would be paid at a rate that subtracted the base code (45378, 9.95 RVUs) that is, 3.57 RVUs.

Bilateral Procedures. Column W tells physicians and coders how a procedure should be paid if it is performed on both sides. Many procedures, however, cannot be billed as bilateral simply because two sides do not exist; Such procedures will show a 0 in column W. For example, colonoscopies and cholecystectomies will never be performed bilaterally because the patient has only one colon and one gallbladder. Alternatively, if the procedure can be performed on two sides, and there are distinct codes for the procedure when performed bilaterally and unilaterally, the unilateral procedure will show a 0 in column W as well.

If the procedure shows a 1 in column W and is reported with modifier -50 (bilateral procedure), or by any other means such as -RT (right side) and -LT (left side) modifiers or with a 2 in the units field of the HCFA 1500 claims form there is a 150 percent payment adjustment, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions in Lakewood, N.J.

Note: According to HCFA, if the bilateral procedure is performed at the same time as other procedures, the bilateral adjustment should be applied before any multiple procedure adjustment is made.

If column W contains a 2, no fee adjustment should be made because the RVUs for the code assume a bilateral procedure. According to HCFA, this is the case when (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure. In the rare event that a procedure performed bilaterally includes a 3 in column W, both sides should be billed at 100 percent, for a total of 200 percent. A 9 in column W indicates that the concept of bilateral procedure does not apply.

Co- and Assistant Surgery. Columns X and Y indicate the circumstances that will allow assistant and co-surgeons to be paid. For assistant surgery, a 0 in column X indicates that supporting documentation is required when submitting the claim, and a 1 means that the assistant surgeons claim will not be paid in any event. A 2 indicates the procedure will be paid. If column X contains a 3, the concept of assistant surgery does not apply.

Note: Assistant surgeons receive 16 percent of the fee paid to the primary surgeon. This fee is paid over and above the primary surgeons reimbursement.

The categories for co-surgery are similar. A 0 in column Y indicates that supporting documentation should be submitted, whereas a 1 means that HCFA will not pay two surgeons for the service. If column Y contains a 2, the claim will be paid without question. As is the case with assistant surgery, a 3 indicates the concept does not apply.

Note: Co-surgery pays 125 percent of the fee that would be paid to a single surgeon. That 125 percent is divided in two, giving each surgeon 62.5 percent of the fee paid to a lone surgeon.

Physician Supervision. This field does not relate to payment, but instructs physicians as to the kind of supervision they need to provide if ancillary providers, such as physician assistants or nurse practitioners, perform services. A 1 in column AA indicates that general supervision (physician is available by telephone) is required; a 2 indicates direct supervision (physician must be in the suite or office, but not necessarily in the same room as the ancillary provider and the patient); and a 3 indicates personal supervision, meaning the physician must be in the same room as the patient and the provider. If column AA contains a P, HCFA has not reached a decision on the kind of supervision required for the procedure.

Supplies. Column AB indicates which HCPCS code may be billed (if any) for specific procedures. For example, in our sample, surgeons can bill HCPCS code A4550 (surgical trays) for all three colonoscopy codes. None of the other codes in the sample allow billing of supplies.

Other Categories. The other fields in the fee schedule do not contain information that is as pertinent to the day-to-day requirements of surgeons and their coders. There may be data that are useful at certain times (for example, team surgery requirements), however, and information on how to interpret this data is available from the supporting files that are packaged together with the downloaded Excel-based fee schedule (specifically RVUPUF01.doc) available at www.hcfa.gov.