DOS reporting for pre-operative test

Outpatient Hospital Requirements

Outlined below are generally accepted billing guidelines.

Submit one bill to Florida Blue for: All services provided on the day or within 72 hours, unless otherwise specified in your contract, of a surgical procedure being performed. This includes all charges for pre-operative testing, or ER, ER to observation, or any outpatient services continuously provided that span multiple days.

• Span date billing for services other than surgery and related services within 72 hours (e.g., span dates for serial services, such as physical therapy and chemotherapy) should not be done unless specified differently in your contract because pricing may be applied incorrectly under a cap or threshold. If span date billing is allowed under your contract, then submit actual dates of service on different lines and submit a separate line for each different CPT or HCPCS procedure code reported

• No interim or split bills.

Include charges for preoperative testing related to surgery on the same bill as the surgery, whether or not the testing was provided on the date of surgery. The span date should reflect the date of the testing through the date of the surgery. The From Date and Admission Date will be the same if pre-operative services were performed.

• Submit the date of service on each detail line.

• CPT or HCPCS codes must be reported on each detail line when the revenue code is one of the codes listed here.

• Bill physician/professional fees (0960-0989) on a CMS-1500 form only.

• Florida Blue accepts and adjudicates claims with up to 12 diagnosis codes and up to 6 procedure codes.

• Appropriate modifier codes should be reported for accurate application of Correct Coding Initiative (CCI) edits.

How much payment would get Assitant Surgeon, Co- Surgery and Team surgery

Assistant Surgeon Services

Harvard Pilgrim reimburses assistant surgeon services when the assistant at surgery is a physician, a physician assistant, or a nurse practitioner consistent with CMS’ determination of approved procedure codes payable to an assistant surgeon.

• Assistant surgeon services are reimbursed at 16% of the fee schedule/allowable amount.
• Secondary surgical procedures are reimbursed at 8% of the fee schedule/allowable amount.


Assistant Surgeon Services (in Maine only)
Registered nurse/first assistants and physician assistants are reimbursed as assistant surgeons at a rate equal to 85% of the assistant surgeon 16% allowable rate.


Co-Surgery
Co-surgery is reimbursed at 62.5% of the fee schedule/allowable amount.


Team Surgery
Team surgery is reimbursed after individual consideration and review of operative notes according to the percentage of surgery performed by each respective surgeon.

Attempted Service (discontinued procedure)
Attempted inpatient surgery is reimbursed at 50% of the fee schedule/allowable amount.

Reduced Services
Reduced services are reimbursed at 50% of the fee schedule/allowable amount.

Procedures

Kyphoplasty, vertebroplasty, and radiologic supervision and interpretation, vertebroplasty for multiple myeloma, monostatic and solitary myeloma, spinal cord hemangioma, secondary malignant neoplasm bone and bone marrow, osteoporotic vertebral collapse and vertebral hemangioma.


First Assistant in Surgery

Louisiana Medicaid will reimburse for only one first assistant in surgery. Ideally, the first assistant to the surgeon should be a qualified physician. However, in those situations when a physician does not serve as the first assistant; qualified, enrolled, advanced practice registered nurses and physician assistants may function in the role of a surgical first assistant and submit claims for their services under their Medicaid provider number. The reimbursement of claims for more than one first assistant is subject to recoupment.



Reimbursement

• Unless otherwise excluded by the Medicaid Program, coverage of services will be determined by individual licensure, scope of practice, and terms of the physician collaborative agreement. Collaborative agreements must be available for review upon
request by authorized representatives of the Medicaid program.

• Immunizations and KIDMED medical, vision, and hearing screens are reimbursed at 100% of the physician fee on file. All other payable procedures are reimbursed at 80% of the physician fee on file.

• Qualified CNS/CNPs who perform as first assistant in surgery should use the “AS” modifier to identify these services.

Insurance payment for E & M service on Global day and multiple procedures

Significant, Separately Identifiable E&M with Global Day Service—Same Day

Policy will apply to all professional services performed in an office place of service, when significant, separately identifiable E/M service (appended with 25 modifier) and any service that has a global period indicator as designated by CMS of 0, 10, 90 or YYY is performed on the same day, E&M service will be reimbursed at 50% of the contracted allowable. When the E&M value is greater than the procedure, the reduction will be applied to the global procedure code.


Bundled Services
Harvard Pilgrim reimburses only the most intensive CPT code when:

• A procedure is considered to be normally included as part of a more comprehensive code.

• A single, more comprehensive CPT code more accurately describes a group of procedures.
• If a procedure that is generally carried out as an integral part of a larger surgical procedure is performed alone and independent of other surgical services, it is reimbursable.


Multiple Procedures

• When multiple procedures are performed at the same session, the primary procedure is reimbursed at 100% of the allowable rate and all subsequent reimbursable procedures are paid at 50% of the allowable rate.

• Harvard Pilgrim determines the primary procedure based on the highest allowable rate, not the charge.


Bilateral Surgeries

• Bilateral surgeries are reimbursed at 150% of the allowable rate.
• Bilateral assistant surgeons are reimbursed at 16% of the allowable 150% amount.


Professional, Multiple and Bilateral Surgery Services Performed During the Same Operative Session

When a bilateral procedure code and surgical procedure(s) are performed at the same session and eligible for multiple procedure reduction, claim will be subject to multiple procedure reduction and bilateral procedure payment adjustment in accordance with Harvard Pilgrim payment policy. If the bilateral procedure is the secondary procedure, multiple procedure reduction and bilateral procedure payment adjustment will be applied.


Add-on Codes

• Add-on codes are reimbursed at 100% of the allowable rate and are not subject to the multiple procedure reduction.

• Add-on codes are only those codes designated by CPT and identified by a specific descriptor that includes the phrase

“each additional” or “list separately in addition to the primary procedure.”
• Add-on codes are reimbursable only when billed with their primary procedure.

Cosmetic Surgery

Cosmetic surgery is reimbursable with prior authorization of any cosmetic surgery exceptions, including, but not limited to:

• Repair of an accidental injury (e.g., repair of the face following a serious automobile accident).

• Improved function of a malformed body part.

• Treatment of severe burns.

• For additional information, refer to the Cosmetic, Reconstructive and Restorative Procedures Payment Policy.


E&M services provided within global period

Based on the CMS global surgical period:

• FCHP does not separately reimburse for any E&M service when reported with major surgical procedures (90-day global surgical period)

• FCHP does not separately reimburse for any E&M service when reported with minor procedures with a 10-day post-op period.

• FCHP does separately reimburse for new patient E&M services and E&M services described in Proceure  as applying to new or  established patients when reported with minor procedures with a 0-day post-op period.

• FCHP does consider reimbursement for services rendered during the global period if the appropriate modifier -24 is appended to the E&M procedure code and medical notes are included.


Services rendered in the office after-hours or on weekends or holidays

• FCHP reimburses Proceure  Code 99050 for services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday), in addition to basic service.

• FCHP reimburses Proceure  Code 99051 for services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.

what is Pre-operative Period Billing and post operative billing ? Which modifier can use ?

Pre-operative Period Billing

E /M Service Resulting in the Initial Decision to Perform Surgery

Evaluation/ Management (E/M) services on the day before major surgery or on the day of major
surgery that result in the initial decision to perform the surgery are not included in the global surgery
payment for the major surgery and, therefore, may be billed and paid separately. In addition to the CPT E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery. The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. Carriers/MACs may not pay for an E/M service billed with the CPT modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10 day global surgical period.

Day of Procedure Billing

Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure Modifier “-25” (Significant, separately identifiable E/M service by the same physician on the same day of the procedure), indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service.

•Use modifier “-25” with the appropriate level of E/M service.
•Use modifiers “-24” (Unrelated E/M service by the same physician during a post-operative period) and “-25” when a significant, separately identifiable E/M service on the day of a procedure falls within the post-operative period of another unrelated, procedure.

Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.

Claims for Multiple Surgeries
Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day. Surgeries subject to the multiple surgery rules have an indicator of “2” in the Physician Fee Schedule look-up tool. The multiple procedure payment reduction will be applied based on the MPFS approved amount and not on the submitted amount from the providers. The major surgery may or may not be the one with the larger submitted amount.

Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. These intra-operative services, incidental surgeries, or components of more major surgeries are not separately billable.
There may be instances in which two or more physicians each perform distinctly different, unrelated surgeries on the same patient on the same day (for example, in some multiple trauma cases). When this occurs, the payment adjustment rules for multiple surgeries may not be appropriate.

Claims for Co-Surgeons and Team Surgeons

Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedures and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery. The following billing procedures apply when billing for a surgical procedure or procedures that require the use of two surgeons or a team of surgeons:

•If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-62” (Two surgeons). Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements. Certain services that require documentation of medical necessity for two surgeons are identified in the MPFS look-up tool.
•If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-66” (Surgical team). Certain services, as identified in the MPFS look-up tool, submitted with modifier “-66” must be sufficiently documented to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow pricing “by report.”

• If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon’s services.

Post-Operative Period Billing

Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period

Two CPT modifiers are used to simplify billing for visits and other procedures that are furnished during the post-operative period of a surgical procedure, but not included in the payment for surgical procedure.

• Modifier “-79” (Unrelated procedure or service by the same physician during a post-operative period). The physician may need to indicate that a procedure or service furnished during a post-operative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.

• Modifier “-24” (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure.

Global Surgery Coding and Billing Guidelines - what modifier to use

Physicians Who Furnish the Entire Global Package

Physicians who furnish the surgery and furnish all of the usual pre-and post-operative work may bill for the global package by entering the appropriate CPT code for the surgical procedure only. Separate billing is not allowed for visits or other services that are included in the global package. When different physicians in a group practice participate in the care of the patient, the group practice bills for the entire global package if the physicians reassign benefits to the group. The physician who performs the surgery is reported as the performing physician.

Physicians Who Furnish Part of a Global Surgical Package

More than one physician may furnish services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the post-operative, post-discharge care is split among two or more physicians where the physicians agree on the transfer of care. When more than one physician furnishes services that are included 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 provided all services, except where stated policies allow for higher payment. For instance, when the surgeon furnishes only the surgery and a physician other than the surgeon furnishes pre-operative and post-operative inpatient care, the resulting combined payment may not exceed the global allowed amount. The surgeon and the physician furnishing the post-operative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case. Split global-care billing does not apply to procedure codes with a zero day post-operative period.

Using Modifiers “-54” and “-55”

Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier:

• Surgical care only (modifier “-54”); or

• Post-operative management only (modifier “-55”). For global surgery services billed with modifiers “-54” or “-55,” the same CPT code must be billed. The same date of service and surgical procedure code should be reported on the bill for the surgical care only and post-operative care only. The date of service is the date the surgical procedure was furnished. Modifier “-54” indicates that the surgeon is relinquishing all or part of the post-operative care to a physician.

• Modifier “-54” does not apply to assistant-at-surgery services.

• Modifier “-54” does not apply to an Ambulatory Surgical Center (ASC’s) facility fees. The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.”

• Use modifier “-55” with the CPT procedure code for global periods of 10 or 90 days.

• Report the date of surgery as the date of service and indicate the date care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.

• The receiving physician must provide at least one service before billing for any part of the post-operative care.

• This modifier is not appropriate for assistant-at- surgery services or for ASC’s facility fees.

Exceptions to the Use of Modifiers “-54” and “-55”

Where a transfer of care does not occur, occasional  post-discharge services of a physician other than the surgeon are reported by the appropriate E/M code. No modifiers are necessary on the claim.
Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier. If the services of a physician other than the surgeon are required during a post-operative period for an underlying condition or medical complication, the other physician reports the appropriate E/M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.



GLOBAL SURGERY PERIOD

Louisiana Medicaid’s global surgery period (GSP) policy differs from Louisiana Medicare policy.

• Medicaid does not pay for the day before, the day of, and the assigned GSP after surgery. Louisiana Medicaid assigns a GSP 1, 10, or 90 days. If you look at the  Professional Fee Schedule, the Global Surgery Period can be found in column 11.

• If a procedure has a GSP of “1”, the provider cannot bill for an evaluation and management service (E/M) the day before or the day of the procedure.

• If a procedure has a GSP of “10”, the provider cannot bill for an E/M service the day before, the day of, or 10 days following the procedure.

• If a procedure has a GSP of “90”, the provider cannot bill for an E/M service the day before, the day of, or 90 days following the procedure.

• Error code 690 (payment included in surgery fee) results when an E/M service is denied for a date of service within the GSP of the surgery or procedure that has been paid.

• Error code 691 (visit paid in GSP; void visit, rebill surgery) results when a surgery or procedure is denied because an E/M service has been paid for a date of service within the GSP of the surgery or procedure. The paid claim for the E/M service must be voided before the claim for the surgery or procedure can be considered for payment.

• E/M services should be billed separately only if the diagnosis and service rendered are unrelated to the diagnosis of the GSP procedure. If a visit is to be billed for a date of service within the GSP for unrelated diagnosis, it should be filed on a claim form separate from that of the GSP surgery or procedure.




Surgeons and Global Surgery

A national definition of a global surgical package has been established to ensure that payment is made consistently for the same services across all carrier jurisdictions, thus preventing Medicare payments for services that are more or less comprehensive than

intended. The national global surgery policy became effective for surgeries performed on and after January 1, 1992.

The instructions that follow describe the components of a global surgical package and payment rules for minor surgeries, endoscopies and global surgical packages that are split between two or more physicians. In addition, billing, mandatory edits, claims review, adjudication, and postpayment instructions are included.

In addition to the global policy, uniform payment policies and claims processing requirements have been established for other surgical issues, including bilateral and multiple surgeries, co-surgeons, and team surgeries.

Definition of a Global Surgical Package

Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with entries of 000, 010, 090, and, sometimes, YYY.

Codes with “090” in Field 16 are major surgeries. Codes with “000” or “010” are either minor surgical procedures or endoscopies.

Codes with “YYY” are carrier-priced codes, for which carriers determine the global period (the global period for these codes will be 0, 10, or 90 days). Note that not all carrier-priced codes have a “YYY” global surgical indicator; sometimes the global period is specified.

While codes with “ZZZ” are surgical codes, they are add-on codes that are always billed with another service. There is no postoperative work included in the fee schedule payment for the “ZZZ” codes. Payment is made for both the primary and the add-on codes, and the global period assigned is applied to the primary code.

A.Components of a Global Surgical Package


Carriers apply the national definition of a global surgical package to all procedures with the appropriate entry in Field 16 of the MFSDB.

The Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery. The services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, physicians’ offices. Visits to a patient in an intensive care or critical

care unit are also included if made by the surgeon. However, critical care services (99291 and 99292) are payable separately in some situations.

*Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;

*Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a surgical procedure;

*Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room;

*Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery;

*Postsurgical Pain Management - By the surgeon;
*Supplies - Except for those identified as exclusions; and
*Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

B.Services Not Included in the Global Surgical Package

Carriers do not include the services listed below in the payment amount for a procedure with the appropriate indicator in Field 16 of the MFSDB. These services may be paid for separately.

*The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure;

*Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;

*Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;

*Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;

*Diagnostic tests and procedures, including diagnostic radiological procedures;
*Clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment for complications. (A new postoperative period begins with the subsequent procedure.) This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. Examples of this are procedures to diagnose and treat epilepsy (codes 61533, 61534-61536, 61539, 61541, and 61543) which may be performed in succession within 90 days of each other;

*Treatment for postoperative complications which requires a return trip to the operating room (OR). An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR);

*If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;

*For certain services performed in a physician’s office, separate payment can no longer be made for a surgical tray (code A4550). This code is now a Status B and is no longer a separately payable service on or after January 1, 2002. However, splints and casting supplies are payable separately under the reasonable charge payment methodology;

*Immunosuppressive therapy for organ transplants; and
*Critical care services (codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.


C.Minor Surgeries and Endoscopies

Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.

A postoperative period of 10 days applies to some minor surgeries. The postoperative period for these procedures is indicated in Field 16 of the MFSDB. If the Field 16 entry is 010, carriers do not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure. If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the

10-day period, the major surgery is payable separately. Services by other physicians are not included in the global fee for a minor procedures except as otherwise excluded. If the Field 16 entry is 000, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. Separate payment is made in this instance.

D.Physicians Furnishing Less Than the Full Global Package B3-4820-4831
There are occasions when more than one physician provides services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the postoperative, post- discharge care is split between two or more physicians where the physicians agree on the transfer of care.

When more than one physician furnishes services that are included 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, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care, result in payment that is higher than the global allowed amount).

Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.

E.Determining the Duration of a Global Period

To determine the global period for major surgeries, carriers count 1 day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery.

EXAMPLE:

Date of surgery - January 5 Preoperative period - January 4
Last day of postoperative period - April 5

To determine the global period for minor procedures, carriers count the day of surgery and the appropriate number of days immediately following the date of surgery.

EXAMPLE:

Procedure with 10 follow-up days:

Date of surgery - January 5
Last day of postoperative period - January 15

Medicare endoscopic payment pricing method - Multiple procedure

Endoscopic Pricing Method

The endoscopic pricing method is denoted by an indicator of (3) under the “Mult Proc” column on the MPFSDB.

Calculate the allowance and limiting charge (non-assigned claims only) at:

One hundred percent for the procedure with the highest fee schedule amount.

Subsequent procedures equal subsequent procedure allowance minus basic endoscopic allowance.
The pricing formula for multiple endoscopic procedures varies depending on which procedures are billed.

Same Endoscopic Family

When two or more endoscopies are billed that are both in the same endoscopic family, Medicare prices the highest allowed procedure at 100 percent of the fee amount. The other procedures are priced by subtracting the fee amount of the basic endoscopy from their fee amounts.

Example: The following example demonstrates endoscopic pricing in the same endoscopic family.


Codes                Definition           Indicator Fee Amount $      Allowance $ 
45305©  Proctosigmoidoscopy w/bx 3 130.39 – 68.08 =       62.31 x 80%
45307© Proctosigmoidoscopy fb      3  138.62                      138.62 x 80%

Base Endoscopy

45300© Proctosigmoidoscopy dx 2   68.08

Different Endoscopic Family
When two or more endoscopies that are both in the same endoscopic family are billed along with another procedure that is either non-endoscopic or endoscopic from a different family, price the two endoscopies that are in the same family as indicated in Example 1. The allowance of the two procedures should be added together and then compared to the third procedure.

Example: The following example demonstrates endoscopic pricing from different endoscopic families.

Codes     Definition                     Indicator             Fee Amount $                        Allowance $
*45305© Proctosigmoidoscopy w/bx 3                 130.39 – 68.08 =  62.31        31.16  x 80%
                                                                            62.31 x 50% = 31.16
*45307© Proctosigmoidoscopy fb   3                138.62   138.62 x 50% = 69.31   69.31  x 80%

52325© Cystoscopy, stone removal 3        304.06 @ full physician allowance     304.06 x 80%

Heel Surgery CPT Codes 28100, 28118, 28060 and covered DX

Heel Surgery

CPT Codes
• 28100 talus or calcaneus exostectomy
• 28118 ostectomy calcaneus
• 28119 ostectomy calcaneus for spur with or without plantar fascial release
• 28008 fasciotomy foot or toe
• 28060 fasciectomy, plantar fascia, partial

 Common diagnoses:
• 726.73 calcaneal spur
• 727.3 bursitis
• 728.71 plantar fasciitis