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Outpatient Surgical Reimbursement

Policy ID: NDRP_Surg_011
Section: Outpatient Surgical Reimbursement
Effective Date: July 01, 2018
Last Reviewed: September 13, 2019

Description:

This policy addresses the reimbursement for outpatient surgical claims.

Policy:

The reimbursement process for outpatient surgical claims is described by a surgical roll-up. The roll-up applies to claims with surgical procedures that initiate the remainder of the roll-up process. All surgical procedures that initiate the surgical roll-up are specified on the outpatient fee schedule by attribute indicators of 7, 11 or 13.

If one or more of the surgical codes specified by attribute indicators 7, 11 or 13 are billed on an outpatient claim, charges on specific revenue codes associated with the surgery will be added together and the surgical roll-up will apply. The total of all covered charges, including packaged services related to the surgery and the revenue codes shown below, is compared to the fee schedule rate for the surgical procedure(s) present on the claim.

Packaged services are identified with attribute indicators 10 or 16 on the outpatient fee schedule. These procedures or items related to surgery are considered packaged according to the Medicare Outpatient Prospective Payment System (OPPS) status indicator “N.” Surgical procedures are reimbursed at full, half, half, etc. Reimbursement is the lesser of the total surgical charges or the total fee schedule amount. Any additional services not included in the surgical roll-up are reimbursed at their appropriate fee schedule rate. Examples of services not included in the surgical roll-up are lab, radiology, home medical equipment and therapy. These services require appropriate HCPCS and revenue code(s).

The following revenue codes apply the surgical roll-up (this list is reviewed and updated annually):

0250 0262 0279 0379 0515 0621 0721 0769
0251 0263 0360 0481 0516 0622 0722 0790
0252 0264 0361 0489 0517 0623 0723 0901
0253 0269 0362 0490 0519 0636** 0724 0912
0256 0270 0367 0499 0520 0637 0729 0913
0257 0271 0369 0510 0521 0700 0750 0920
0258*** 0272 0370 0511 0522 0709 0759 0929
0259 0275 0371 0512 0523 0710 0760 0940
0260 0276 0372 0513 0526 0719 0761 0949
0261 0278* 0374 0514 0529 0720 0762

 

*See specific Level II HCPCS, as specified on the outpatient fee schedule by attribute indicators 9 and 15, which will be allowed for separate payment and will not be included in the surgical allowance when billed with revenue code 0278.

**See specific Level II HCPCS, as specified on the outpatient fee schedule by attribute indicators 8 and 14, which will roll into the total surgical charges when billed with revenue code 0636 and will not receive separate payment. An exception to this rule is when heparin is billed with a procedure to which it’s included in; in this case, the heparin wouldn’t roll with the surgical procedure, it would deny as inclusive of the other procedure. A list of procedures that include heparin is available on CMS’s PE Supplies list.

***Revenue code 0258 requires specific HCPCS when billed on all surgical and medical claims. This revenue code is part of the surgical roll-up for surgical claims.

Surgical codes should be submitted on the same claim for the same stay. Units for surgical procedure codes must always be one (1). Bilateral procedures should follow the Bilateral Procedures Reimbursement Policy to obtain correct reimbursement. Use of modifier 73 (discontinued procedure prior to anesthesia) will result in a 50% reduction to the fee schedule amount for the procedure.

The presence of a code on the listing of surgical procedures does not indicate coverage. Medical policies and benefit plan variations continue to apply.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross Reference:

Bilateral Procedures Reimbursement Policy