TRICARE Reimbursem*nt Manual 6010.64-M, April 2021
General
Chapter 1
Section 16
Surgery
Issue Date:August 26, 1985
Authority:32 CFR 199.4(c)(2)(i), (c)(2)(ii), (c)(3)(i), (c)(3)(iii), and (c)(3)(iv)
Copyright:CPT only © 2006 American MedicalAssociation (or such other date of publication of CPT).All Rights Reserved.
Revision:
1.0APPLICABILITY
Paragraphs 3.1 through 3.7 applyto reimbursem*nt of services provided by network and non-networkproviders. Paragraphs 3.8 and 3.9 applyonly to non-network providers.
2.0ISSUE
How is surgery to be reimbursed?
3.0POLICY
3.1MultipleSurgery And Discounting Reimbursem*nt
3.1.1The followingrules are to be followed whenever there is a terminated procedureor more than one surgical procedure performed during the same operativeor outpatient session. This applies to those facilities that areexempt from the hospital Outpatient Prospective Payment System (OPPS)and for claims submitted by individual professional providers forservices rendered on or after May 1, 2009 (implementation of OPPS):
3.1.1.1Discountingfor Multiple Procedures
3.1.1.1.1When more than one surgicalprocedure code subject to discounting (see Chapter 13, Section 3)is performed during a single operative or outpatient session, TRICAREwill reimburse the full payment and the beneficiary will pay thecost-share/copayment for the procedure having the highest paymentrate. Beginning January 1, 2015, Medicare introduced comprehensiveAmbulatory Payment Classifications (APCs) under the OPPS. Surgicalprocedures considered part of comprehensive APCs (Status Indicator(SI) of J1) provided in facilities exempt from OPPSare also subject to discounting for multiple procedures under thisparagraph, in addition to those procedures listed in Chapter 13, Section 3.
3.1.1.1.2Fifty percent (50%) of theusual payment amount and beneficiary copayment/cost-share amount willbe paid for all other procedures subject to discounting (see Chapter 13, Section 3) performed during thesame operative or outpatient session to reflect the savings associatedwith having to prepare the patient only once and the incrementalcosts associated with anesthesia, operating and recovery room use,and other services required for the second and subsequent procedures.
•The reduced payment would applyonly to the surgical procedure with the lower payment rate.
•The reduced payment for multipleprocedures would apply to both the beneficiary copayment/cost-shareand the TRICARE payment.
Note:Certain codes are consideredan add-on or modifier 51 exempt procedure for non-OPPSprofessional and facility claims, which should not apply a reductionas a secondary procedure. These codes should not be subject to OPPSdiscounting reduction defined in Chapter 13, Section 3.The source for these codes is the American Medical Association (AMA)Current Procedural Terminology (CPT) guide.
3.1.1.2Discounting for Bilateral Procedures
Note:Bilateral codes can be surgicaland non-surgical.
3.1.1.2.1Following are the differentcategories/classifications of bilateral procedures:
•Conditional bilateral (i.e.,procedure is considered bilateral if the modifier 50 ispresent).
•Inherent bilateral (i.e., procedurein and of itself is bilateral).
•Independent bilateral (i.e.,procedure is considered bilateral if the modifier 50 ispresent, but full payment should be made for each procedure (e.g.,certain radiological procedures).
3.1.1.2.2Terminated bilateral proceduresor terminated procedures with units greater than one should not occur.Line items with terminated bilateral procedures or terminated procedureswith units greater than one are denied.
3.1.1.2.3Inherent bilateral procedureswill be treated as a non-bilateral procedure since the bilateralismof the procedure is encompassed in the code.
3.1.1.2.4The above bilateral procedureswill be discounted based on the application of discounting formulasappearing in Chapter 13, Section 3.
3.1.1.3Modifiersfor Discounting Terminated Surgical Procedures
3.1.1.3.1Industry standard modifiersmay be billed on outpatient hospital or individual professionalclaims to further define the procedure code or indicate that certainreimbursem*nt situations may apply to the billing. Recognition andutilization of modifiers are essential for ensuring accurate processingand payment of these claim types.
3.1.1.3.2Industry standard modifiersare used to identify surgical procedures which have been terminated priorto and after the delivery of anesthesia.
•Modifiers 52 and 73 areused to identify a surgical procedure that is terminated prior tothe delivery of anesthesia and is reimbursed at 50% of the allowable;i.e., the Ambulatory Surgery Center (ASC) tier rate, the APC allowableamount for OPPS claims, or the CHAMPUS Maximum Allowable Charge(CMAC) for individual professional providers.
•Modifiers 53 and 74 areused for terminated surgical procedures after delivery of anesthesiawhich are reimbursed at 100% of the appropriated allowable amountsreferenced above.
3.1.2Exceptions to the above policyprior to implementation of the hospital OPPS, are:
3.1.2.1If the multiple surgical proceduresinvolve the fingers or toes, benefits for the third and subsequent proceduresare to be limited to 25% to the prevailing charge.
3.1.2.2Incidental procedures. No reimbursem*ntis to be made for an incidental procedure.
3.1.3Separate payment is not madefor incidental procedures. The payment for those procedures are packagedwithin the primary procedure with which they are normally associated.
3.1.4Data which is distorted becauseof these multiple surgery procedures (e.g., where the sum of the chargesis applied to the single major procedure) must not be entered intothe data base used to develop allowable charge profiles.
3.1.5TheInpatient Only Procedure List
3.1.5.1The OPPS inpatient only listshall apply to OPPS, non-OPPS, and, through September 30, 2015, individualprofessional providers.
3.1.5.2 Beginning October 1, 2015,the inpatient only list shall no longer apply to the services renderedby individual professional providers. Refer to Chapter 13, Section 5. The inpatient onlylist is available on Defense Health Agency’s (DHA’s) website at http://www.health.mil/rates.
3.1.5.3Beginning April 1, 2017, theinpatient only list shall no longer apply to the services renderedby hospital outpatient departments in states with Centers for Medicareand Medicaid Services (CMS) waivers (e.g., Maryland).
3.2Multiple Primary Surgeons
When more than one surgeonacts as a primary surgeon for multiple procedures during the sameoperative session, the services of each may be covered, subjectto the following considerations:
•For co-surgeons (modifier 62),TRICARE pays 125% of the global fee and divides the payment equallybetween the two surgeons. This means that each surgeon receives62.5% of the TRICARE allowable charge for each procedure. No paymentmay be made for an assistant surgeon in such cases.
•For team surgery (modifier 66),payment needs to be determined on a case-by-case basis. Team surgerycases may be seen with organ transplants, separation of siamesetwins, severe trauma cases, and cases of a similar nature.
•Payment may not be made toany of the primary surgeons for assisting any of the other primarysurgeons.
3.3AssistantSurgeons
See Section 17.
3.4Pre-OperativeCare
Pre-operative care renderedin a hospital when the admission is expressly for the surgery isnormally included in the global surgery charge. The admitting historyand physical is included in the global package. This also appliesto routine examinations in the surgeon’s office where such examinationis performed to assess the beneficiary’s suitability for the subsequentsurgery.
3.5Post-Operative Care
All services provided by thesurgeon for post-operative complications (e.g., replacing stitches,servicing infected wounds) are included in the global package ifthey do not require additional trips to the operating room. Allvisits with the primary surgeon during the 90-day period followingmajor surgery are included in the global package.
Note:This rule does not apply ifthe visit is for a problem unrelated to the diagnosis for whichthe surgery was performed or is for an added course of treatmentother than the normal recovery from surgery. For example, if after surgeryfor cancer, the physician who performed the surgery subsequentlyadministers chemotherapy services, these services are not part ofthe global surgery package.
3.6Re-OperationsFor Complications
All medicallynecessary return trips to the operating room, for any reason andwithout regard to fault, are covered.
3.7GlobalSurgery For Major Surgical Procedures
Physicians who perform theentire global package which includes the surgery and the pre- andpost-operative care should bill for their services with the appropriateCPT code only. Do not bill separately for visits or other services includedin this global package. The global period for a major surgery includesthe day of surgery. The pre-operative period is the first day immediatelybefore the day of surgery. The post-operative period is the 90 calendar daysimmediately following the day of surgery. If the patient is returnedto surgery for complications on another day, the post-operativeperiod is 90 calendar days immediately after the last operation.
3.8SecondOpinion
3.8.1Claims for patient-initiated,second-physician opinions pertaining to the medical need for surgeryor other major nonsurgical diagnostic and therapeutic procedures(e.g., invasive diagnostic techniques such as cardiac catheterizationand gastroscopy) may be paid. Payment may be made for the historyand examination of the patient as well as any other covered diagnosticservices required in order for the physician to properly evaluate thepatient’s condition and render a professional opinion on the medicalneed for surgery or other major nonsurgical diagnostic and therapeuticprocedure.
3.8.2In the event that the recommendationsof the first and second physician differ regarding the medical needfor such surgery or other major nonsurgical diagnostic and therapeuticprocedure, a claim for a patient-initiated opinion from a thirdphysician is also reimbursable. Such claims are payable even thoughthe beneficiary has the surgery performed against the recommendationof the second (or third) physician.
3.9In-OfficeSurgery
Chargesfor a surgical suite in an individual professional provider’s office,including charges for services rendered by other than the individualprofessional provider performing the surgery and items directlyrelated to the use of the surgical suite, may not be cost-sharedunless the suite is an approved ASC.
3.10On May1, 2009 (implementation of OPPS), surgical procedures will be discountedin accordance with the provisions outlined in Chapter 13, Section 3. Multiple discountingwill not be applied to the following CPT codes for venipucture,fetal monitoring and collection of blood specimens; 36400-36416,36591, 36592, 59020, 59025, 59050, and 59051.
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