MULTIPLE OR BILATERAL PROCEDURES

As it relates to billing for both related, and unrelated multiple procedures, the same rationale for additional fees is also applicable to hospital outpatient and ambulatory surgical center facility fees but not applicable to inpatient care.

Multiple related procedures shall not warrant an additional fee except in those subsections of the listings where separate codes are given. When more than one identifiable surgical procedure or service is rendered, an additional fee may be warranted. Identify each procedure and bill at full value for the major procedure and at 50% for the lesser procedure, up to four (4) more additional / secondary procedures paid at 50% of the maximum allowable payment. Additional related procedures, beyond the total of five (5) as defined, may be considered for payment on an individual by report (BR) basis.

When multiple procedures, unrelated to the major procedure and adding significant time or complexity are provided at the same operative session, payment is for the procedure with the highest allowance, plus 50% for the lesser procedure, up to four (4) more additional / secondary procedures paid at 50% of the maximum allowable payment. 

When bilateral procedures are performed that require preparation of separate operative sites (e.g., bilateral carpal tunnel), payment for the second (or bilateral) procedure is to be reimbursed at 75% of the primary procedure. 

SURGERY GROUND RULES

PACKAGE OR GLOBAL FEE CONCEPT: Listed surgical procedures include the surgery itself, local anesthesia, metacarpal/digital block, or topical anesthesia when used, and normal, uncomplicated follow-up care. The Unit Values for all procedures in this section applies to this "package" or "global" service for surgical procedures. To report a postoperative follow-up for documentation purposes only, use 99024 (see Special Services and Reports Section). For preoperative visits, see Ground Rules 3 and 4 below; see the respective Anesthesia Ground Rule pertaining to anesthesia administered by other than an anesthesiologist or anesthetist. 

OPERATIVE REPORT AND BILLING: A bill for an operative procedure shall be deemed properly submitted only if an operative report or an informative description of the surgery performed is received by the payer. If surgery was performed in a hospital or an ambulatory surgery center, a copy of the hospital's or ambulatory surgery center's operative report will suffice. If surgery was performed at some other site and classified as minor surgery, such as at a physician's office, identify the (geographic) location and submit an informative description of the surgery performed. 

IMMEDIATE PREOPERATIVE VISITS AND OTHER SERVICES BY THE SURGEON: Under most circumstances, including ordinary referrals, the immediate preoperative visit in the hospital or elsewhere that is necessary to examine the patient, or to initiate the treatment program, is included in the Unit Value listed for the surgical procedure.

SEPARATE PREOPERATIVE CHARGES: Charges for separate preoperative procedures are sometimes warranted and may be billed under the following circumstances: 

a) when the preoperative visit is the initial visit (e.g., an emergency) and prolonged detention or evaluation is required to prepare the patient, or to establish the need for and type of surgical procedure. 

ANESTHESIA

CPT Code Base Unit Value

00100 $255.95 + TM*

00400 $153.57 + TM*

00632 $358.33 + TM*

00102 $307.14 + TM*

00402 $255.95 + TM*

00634 $511.90 + TM*

00103 $255.95 + TM*

 00404 $255.95 + TM*

 00635 $204.76 + TM*

00104 $204.76 + TM*

00406 $665.47 + TM*

00640 $153.57 + TM*

00120 $255.95 + TM*

00410 $204.76 + TM*

00670 $665.47 + TM*

00124 $204.76 + TM*

00474 $665.47 + TM*

00752 $307.14 + TM*

00126 $204.76 + TM*

00500 $767.85 + TM*

00754 $358.33 + TM*

00140 $255.95 + TM*

00520 $307.14 + TM*

00756 $358.33 + TM*

00142 $204.76 + TM*

00522 $204.76 + TM*

 00770 $767.85 + TM*

00144 $307.14 + TM*

00524 $204.76 + TM*

00790 $358.33 + TM*

00145 $307.14 + TM*

00528 $409.52 + TM*

00792 $665.47 + TM*

00147 $204.76 + TM*

00529 $563.09 + TM*

00794 $409.52 + TM*

00148 $204.76 + TM*

00530 $204.76 + TM*

00796 $1535.70 + TM*

00160 $255.95 + TM*

00532 $204.76 + TM*

00797 $563.09 + TM*

00162 $358.33 + TM*

00534 $358.33 + TM*

00800 $204.76 + TM*

00164 $204.76 + TM*

 00537 $358.33 + TM*

00802 $255.95 + TM*

00170 $255.95 + TM*

00539 $921.42 + TM*

00810 $255.95 + TM*

00172 $307.14 + TM*

00540 $614.28 + TM*

 00820 $255.95 + TM*

00174 $307.14 + TM*

00541 $767.85 + TM*

00830 $204.76 + TM*

00176 $358.33 + TM*

00542 $767.85 + TM*

00832 $307.14 + TM*

00190 $255.95 + TM*

00546 $767.85 + TM*

00834 $255.95 + TM*

00192 $358.33 + TM*

00548 $870.23 + TM*

00836 $307.14 + TM*

 00210 $563.09 + TM*

00550 $511.90 + TM*

00840 $307.14 + TM*

00211 $511.90 + TM*

00560 $767.85 + TM*

00842 $204.76 + TM*

00212 $255.95 + TM*

00561 $1279.75 + TM*

00844 $358.33 + TM*

00214 $460.71 + TM*

00562 $1023.80 + TM*

00846 $409.52 + TM*

00215 $460.71 + TM*

00563 $1279.75 + TM*

00848 $409.52 + TM*

00216 $767.85 + TM*

00566 $1279.75 + TM*

00851 $307.14 + TM*

00218 $665.47 + TM*

00567 $921.42 + TM*

00860 $307.14 + TM*

00220 $511.90 + TM*

00580 $1023.80 + TM*

00862 $358.33 + TM*

00222 $307.14 + TM*

00600 $511.90 + TM*

00864 $409.52 + TM*

00300 $255.95 + TM*

00604 $665.47 + TM*

00865 $358.33 + TM*

00320 $307.14 + TM*

00620 $511.90 + TM*

00866 $511.90 + TM*

00322 $153.57 + TM*

 00622 $665.47 + TM*

00868 $511.90 + TM*

00326 $358.33 + TM*

00625 $665.47 + TM*

00870 $255.95 + TM*

00350 $511.90 + TM*

00626 $767.85 + TM*

00872 $358.33 + TM*

00352 $255.95 + TM*

00630 $409.52 + TM*

00873 $255.95 + TM*

00880 $767.85 + TM*

01212 $511.90 + TM*

01610 $255.95 + TM*

00882 $511.90 + TM*

01215 $511.90 + TM*

01622 $204.76 + TM*

00902 $255.95 + TM*

01220 $204.76 + TM*

01630 $255.95 + TM*

00904 $358.33 + TM*

01230 $307.14 + TM*

01634 $460.71 + TM*

00906 $204.76 + TM*

01232 $255.95 + TM*

01636 $767.85 + TM*

00918 $255.95 + TM*

COST CONTAINMENT

Nothing in this section shall preclude an employer (or insurance carrier) from entering into payment agreements to promote the continuity of care and the reduction of health care costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please refer to K.S.A 44-510i(e) for further clarification, if necessary.

NATIONAL CORRECT CODING INITIATIVE (NCCI) EDITS: In order to promote correct coding methodologies and to control improper coding leading to inappropriate payments, the Kansas Division of Workers Compensation Schedule of Medical Fees recognizes the 2014 National Correct Coding Initiatives (NCCI) Edits as established by the Centers for Medicare and Medicaid Services (CMS) as the primary standard of reference. The NCCI Edits are not requirements, nor are they mandates or standards; they simply provide advice for correct coding methodologies. Bills must be itemized by procedure code, date of service, and amount of charge.  

CALCULATION EXAMPLES:

1: In a procedure with a Basic Unit Value of 3.0 requiring one hour and forty-five minutes of anesthesia time, the total value should be determined as follows: 

 Basic Unit Value = 3.0 units 

 105 minutes÷15 minutes = 7.0 units 

 Total value = 10.0 units 

2: In a procedure with a Basic Unit Value of 10.0 requiring four hours and twenty minutes of anesthesia time, the total value should be determined as follows:

Basic Unit Value = 10.0 units 

 First three hours = 12.0 units 

 Subsequent 80 minutes = 8.0 units 

 Total value = 30.0 units 

PROCEDURES/SERVICES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE

Some procedures/services are not accompanied by allowable fees. Procedures/services denoted "by report" (BR) in the maximum fee column are too unusual or variable in the nature of their performance, too new, or too infrequently performed to permit the assignment of a maximum fee. Fees for such procedures/services need to be justified "by report." The report should contain sufficient supportive information to permit proper identification. Pertinent information should be furnished concerning the nature, extent, and need for the procedure or service, the time, the skill, and equipment necessary, etc. For any procedure/service where the maximum fee is "BR," the health care provider shall establish a charge that is consistent with other maximum fees shown in the Schedule. The insurance carrier or selfinsured employer should review all submitted "BR" amounts to assure that an excessive charge for services provided is not occurring. Note also that for any procedures/services not listed within this Fee Schedule, the associated charge(s) will need to be substantiated "by report" (BR).

DEFINITIONS 

New Patient: One who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. 

Established Patient: One who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available. 

Note that no distinction is made between new and established patients in the emergency department. E / M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department. 

ADDITIONAL SPECIAL NOTE

The Kansas Workers Compensation Law specifically dictates that an injured employee shall not be liable for any charges above the amount contained within this fee schedule. The respective section of the Kansas Workers Compensation Law (K.S.A. 44-510j(h)) that prohibits an injured employee for being liable for any charges above the amount contained within this fee schedule reads as follows:

Any health care provider, nurse, physical therapist, any entity providing medical, physical or vocational rehabilitation services or providing reeducation or training pursuant to K.S.A. 44-510g and amendments thereto, medical supply establishment, surgical supply establishment, ambulance service or hospital which accept the terms of the workers compensation act by providing services or material thereunder shall be bound by the fees approved by the director and no injured employee or dependent of a deceased employee shall be liable for any charges above the amounts approved by the director.

Interpreter Services:

 If the services of an interpreter are required for the provision of medical care to a hearing impaired, speech impaired, or other person whose primary language is other than English, the following will apply: 

 Maximum allowable payment for the first hour or less is limited to $35.00. 

 Each additional quarter hour increment of time is to be paid at $8.75 per quarter hour increment. 

 Any reimbursement for necessary travel mileage (including any tolls and parking fees actually incurred) is to be at the rate prescribed for compensation of state officers and employees pursuant to K.S.A. 75- 3203a.