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Reimbursement Policies & Guidelines

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Effective Date: July 5, 2016

Purpose:

Implementation of this policy would provide cost avoidance by preventing E&M services involving a decision for surgery for procedures with 0 or 10 day global surgical from paying. This handling is consistent with CMS guidelines and Horizon NJ Health should be following this approach.

Scope:

This policy applies to the Horizon NJ Health product.

Definitions:

Global payments are fixed-dollar payments inclusive of the care that patients may receive in a given time period, such as 10 days, 30 days, 90 days, a year.

Modifier 57: Used to indicate that a particular Evaluation and Management (E&M) service performed in the preoprerative period of a major surgical procedure resulted in a decision to perform that surgical service.

Major surgical procedure: A surgical procedure that includes a 90-day post-operative period. Major surgical procedures also include a 2-day preoperative period.

Minor surgical procedure: A surgical procedure that includes a 0- or 10-day post-operative period. Minor surgical procedures do not include a preoperative period.

Pre-operative period: The day before and the day of a major surgical procedure.

Policy:

Horizon NJ Health does not allow payment for modifier 57 when appended to a:

  • E&M services that resulted in a minor surgical procedure.
  • When applied to an E&M service for post-operative evaluation.
  • When appended to an E&M service that resulted in an ineligible surgical service.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

(Section 30.6.6; Part C: “CPT Modifier “57” – Decision for Surgery Made Within Global Surgical Period under Modifier 57”)

Procedure:

An E&M service that resulted in a decision to perform a major surgical service performed within the preoperative period of that major surgical procedure that is appropriately appended with modifier 57 will be considered for reimbursement of 100% of the applicable Horizon NJ Health fee schedule.

E&M services billed with a Modifier 57 should be denied if billed in addition to a procedure with a “0” or “10” day global surgical procedure.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Provider Participation Agreement
  • Routine Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.