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. 

MULTIPLE/BILATERAL EXAMPLES

ADD-ON CODES: Certain codes, by the nature of their description and the unit values assigned, have already been reduced, as they are not to be billed as primary procedures. For a complete list of the codes which are considered to be add-on codes, refer to the appropriate appendix found within the most recent publication of the AMA Current Procedural Terminology (CPT). 

CODES THAT ARE NOT CLASSIFIED AS ADD-ON CODES BUT ARE EXEMPT FROM THE MULTIPLE PROCEDURE RULE / MODIFIER -51: For a complete list of the codes which fall into this category, refer to the appropriate appendix found within the most recent publication of the AMA Current Procedural Terminology (CPT).

CODES WHICH INCLUDE CONSCIOUS SEDATION: Certain codes include conscious sedation as an inherent part of providing the procedure. For a complete list of codes that include conscious sedation, refer to the appropriate appendix that is found within the most recent publication of the AMA Current Procedural Terminology (CPT).

FOLLOW-UP OR AFTERCARE: Follow-up care for therapeutic surgical procedures includes all normal postoperative care, that care which is usually a part of the surgical service. Complications, exacerbations, recurrence of the condition, or the presence of other diseases or injuries requiring additional services concurrent with the procedure may warrant additional charges. If such separate charges are made, explain by report with an adequate description. When an additional surgical procedure is performed during any follow-up care and is related to the previously performed procedure but is not an intrinsic part of the latter, the additional procedure will be paid at one-half the maximum allowable payment.  

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 

SUPPLEMENTAL SKILLS

When warranted by the necessity of supplemental skills, values for the services of two or more health care providers and/or anesthetists will be allowed. Substantiate by report.

MONITORING SERVICES: When an anesthesiologist or anesthetist is required to participate in and be responsible for monitoring the general care of the patient during a surgical procedure but does not administer anesthesia, these services are charged on the basis of the extent of the services rendered. Payment is to be made on the basis of the time units the anesthesiologist or anesthetist is in constant attendance for the sole purpose of the monitoring services; therefore, basic unit values are not to be added.  

ANESTHESIA ADMINISTERED, OTHER THAN BY AN ANESTHESIOLOGIST OR ANESTHETIST: Anesthesia fees are not payable when local infiltration, digital block, or topical anesthesia is administered by the operating surgeon or surgical assistants. Such services are included in the Unit Value for the surgical procedure. 

OTHER FEES: The Unit Values for surgery, x-rays, laboratory procedures, consultation and other medical services, and office and hospital visits are listed in the following sections: Surgery, Radiology, Pathology and Laboratory, Medicine, Physical Medicine and Rehabilitation, and Evaluation and Management. A consultation fee is not payable to an anesthesiologist examining the patient prior to administering anesthesia to that patient. No additional charge is to be made for routine follow-up care and observation. 

QUALIFYING CIRCUMSTANCES (more than one may be reported): Many anesthesia services are provided under particularly difficult circumstances depending on factors such as the extraordinary condition of the patient, notable operative conditions, unusual risk factors. This section includes a list of important qualifying circumstances that significantly impact on the character of the anesthetic service provided. These procedures would not be reported alone but would be reported as additional procedure numbers qualifying an anesthesia procedure or service. These modifying units may be added to the basic unit values.