UNLISTED SERVICE OR PROCEDURE

PRIMARY, SECONDARY, OR DELAYED PROCEDURES: A primary procedure is one that is attempted or performed for the first time, irrespective of the relationship to the date of injury or the onset of the condition being treated. Secondary refers to a procedure performed when a condition has been previously treated. For example, where a tendon is lacerated and it is elected to close the laceration without suturing the tendon, the first direct repair of the tendon would constitute a delayed but primary repair. In this example, if the first repair is unsuccessful, any subsequent repair of the tendon would be a secondary procedure. Secondary procedures lie within the content of service. Delayed procedures have the same Maximum Allowable Fee as the primary procedures. 

 PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in the Unit Value column indicates that the amount charged for this service is to be determined "by report" because the service is too unusual or variable to be assigned a Unit Value. Pertinent information should be furnished concerning the nature, extent, and need for the procedure or service, the skill and equipment necessary, etc., using any of the following as indicated: 

Diagnosis (postoperative), pertinent history, and physical findings 

Size, location, and number of lesions or procedures where appropriate 

Major surgical procedure accompanied by an additional procedure 

The closest similar procedure by code number and the associated Unit Value, if possible Operative time 

UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the procedure should be identified and the amount charged substantiated "by report" (BR). Unlisted service or procedure codes usually end in "99." 

CONCURRENT SERVICES BY MORE THAN ONE HEALTH CARE PROVIDER: Charges for concurrent services of two or more health care providers may be warranted under the following circumstances: 

a) Identifiable medical services: Services provided prior to or during the surgical procedure or in the postoperative period are to be charged by the health care provider rendering the service, identified by the appropriate code. Payable fees under this category are unrelated to the surgeon's fee.

b) Assistant surgeon: Identify the surgery performed by using the respective code number along with the appropriate modifier (-80, -81, or -82) and bill at 25% of the code fee. The code number must coincide with that of the primary surgeon. Assistant surgeon fees are not payable when the hospital provides an intern or a resident staff to assist at surgery. 

c) Two surgeons: Under certain circumstances, the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. Identify the surgery performed by using the respective code number along with modifier -62. The total allowable fee may be increased by 25% in lieu of an assistant surgeon=s fee. If the physicians have agreed upon a payment distribution and that agreement is documented and explained in conjunction with the bill, payment is to be made in accordance with the percentage agreed upon. 

In the absence of a prior agreement, the total allowable fee will be divided equally between the two surgeons. 

d) Surgical team: Under some circumstances, highly complex procedures (e.g., open heart or organ transplant surgery) may require the concurrent services of several health care providers, often of different specializations and using various types of complex equipment. These types of services vary widely and a single unit value cannot be assigned. The amount charged should be supported by a narrative report to include itemization of the health care provider, paramedical personnel, and equipment involved. Modifier -66 should be used in this type of situation. 

e) No payment shall be made for more than one assistant surgeon or minimum assistant surgeon without prior authorization unless a trauma team was activated due to the emergency nature of the injury(ies).