3.1.4.1   Have a current license to practice, as applicable;

3.1.4.2   Meet other general certification requirements for the specific provider type;

3.1.4.3   Possess a current and valid Drug Enforcement Agency ("DEA") registration, unless not required by the provider's discipline and scope of practice;

3.1.4.4   Have no previous involuntary termination from participation in Medicare, Medicaid or the Delaware workers' compensation system. Any such involuntary termination shall be considered to be inconsistent with certification;

3.1.4.5   Have no felony convictions in any jurisdiction, under a federal-controlled substance act or for an act involving dishonesty, fraud or misrepresentation. A felony conviction in any jurisdiction under a federal-controlled substance act or for an act involving dishonesty, fraud or misrepresentation shall be considered to be inconsistent with certification;

3.1.4.6   Provide proof of adequate, current professional malpractice and liability insurance.

3.1.5.1   Comply with Delaware workers' compensation laws and rules;

3.1.5.2   Maintain acceptable malpractice coverage;

3.1.5.3   Complete state-approved continuing education courses in workers' compensation every two (2) years from the date of the health care provider's initial certification. A listing of continuing education courses in workers' compensation care approved by the State of Delaware, Department of Labor, Office of Workers' Compensation, will be posted on the Office of Workers' Compensation website. To maintain certification, every two (2) years from the initial date of certification the health care provider must provide written notification to the Office of Workers' Compensation of compliance with the continuing education course requirement noted above, setting forth the name of the course(s) completed and the date of completion;

3.1.5.4   Practice in a best-practices environment, complying with practice guidelines and Utilization Review Accreditation Council ("URAC") utilization review determinations;

3.1.5.5   Agree to bill only for services and items performed or provided, and medically necessary, cost-effective and related to the claim or allowed condition;

3.1.5.6   Agree to inform an employee of his or her liability for payment of non-covered services prior to delivery;

3.1.5.7   Accept reimbursement for and not unbundle charges into separate procedure codes when a single procedure code is more appropriate;

3.1.5.8   Agree not to balance bill any employee or employer. Employees shall not be required to contribute a co-payment or meet any deductibles;

3.1.5.9   Agree to have knowledge of all statements authorized under the certified health care provider's signature and to be responsible for the content of all bills submitted pursuant to the provisions of 19 Del.C. §§2322B, C, E, F;

3.1.5.10  Agree to provide written notification to the Department of Labor, Office of Workers' Compensation, State of Delaware, of any relevant changes to the requirements set forth in the Certification Form within thirty (30) days of the health care provider's knowledge or receipt of notice of any and all such change(s).

4.1.1.1       New (?), changed descriptor (?), add-on (+), modifier 51 exempt (*), or conscious sedation (K) icons

4.1.1.2       Five-digit CPT code number

4.1.1.3       CPT description

4.1.1.4       Maximum allowable reimbursement

4.1.1.5       Maximum reimbursement for professional component modifier 26

4.1.1.6       Maximum reimbursement for technical component modifier TC

4.1.1.7       Follow-up day limits in FUD column

4.1.4.1   For anesthesia fee amounts, the table includes basic relative values. Anesthesia fees are somewhat differently than other services using a relative value, physical status modifiers, qualifying circumstances, and a dollar conversion factor. See the Anesthesia section for an explanation of how anesthesia fee amounts are to be determined.

4.1.4.2   Within each section, you will find definitions and medical terms that explain services provided. Also, in certain sections there is an index of procedures by CPT code identifiers. Use each specific section in addition to general ground rules for clarification of terms and services.

4.1.4.3   The fee schedule is designed to be an accurate and authoritative source of information about medical coding and reimbursement. Every reasonable effort has been made to verify its accuracy and all information is believed reliable at the time of publication.  Absolute accuracy and completeness, however, is neither intended nor guaranteed. The rules and guidelines described herein cannot specifically refer to every payment contingency; the usual, customary, and reasonable fee will govern treatment provided under unusual circumstances.

The health care payment system and fee schedule is in accordance with the following documents, including codes, guidelines and modifiers:

• Current Procedural Terminology, copyright, American Medical Association, 515 N. State St., Chicago, IL 60610, Chicago, 2006;

• HCPCS Level II, U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, 7500 Security Blvd., Baltimore, MD 21244, Baltimore, 2006;

• National Correct Coding Policy Manual in Comprehensive Code Sequence for Part B Medicare Carriers,Version 12.0, U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, 7500 Security Blvd., Baltimore, MD 21244, Baltimore, 2006;

• Relative Value Guide, copyright, American Society of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL 60068-2573, Park Ridge, 2006;

• Diagnosis-Related Group (DRG) classification system, Centers for Medicare and Medicaid Services (CMS), Federal Register, Vol. 70, No. 155, August 2005.

• The follow up days for post-operative care that have been adopted by the Delaware Office of Workers’ Compensation for their Fee Schedule and Guidelines have been established by reference to CMS (Centers for Medicare and Medicaid Services).

• $25.00 for search and retrieval
• $1.25 per page for first 20 pages
• $.90 per page for pages 21 through 60
• $.30 per page for pages 61 and thereafter

“Adjust” means that a payer or a payer's agent reduces or otherwise alters a health care provider's request for payment.

“Appropriate care” means health care that is suitable for a particular patient, condition, occasion, or place.

“Bill” means a claim submitted by a provider to a payer for payment of health care services provided in connection with a covered injury or illness.

“Bill adjustment” means a reduction of a fee on a provider's bill, or other alteration of a provider's bill.

“Carrier” means any stock company, mutual company, or reciprocal or inter-insurance exchange authorized to write or carry on the business of Workers' Compensation Insurance in this State, or self-insured group, or third-party payer, or self-insured employer, or uninsured employer.

“CMS-1500” means the CMS-1500 form and instructions that are used by non institutional providers and suppliers to bill for outpatient services. Use of the most current CMS-1500 form is required.

“Case” means a covered injury or illness occurring on a specific date and identified by the worker's name and date of injury or illness.

“Consultation” means a service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. If a consultant, subsequent to the first encounter, assumes responsibility for management of the patient's condition, that physician becomes a treating physician. The first encounter is a consultation and shall be billed and reimbursed as such. A consultant shall provide a written report of his/her findings. A second opinion is considered a consultation.

“Critical care” means care rendered in a variety of medical emergencies that requires the constant attention of the practitioner, such as cardiac arrest, shock, bleeding, respiratory failure, postoperative complications, and is usually provided in a critical care unit or an emergency department.

“Day” means a continuous 24-hour period.

“Diagnostic procedure” means a service that helps determine the nature and causes of a disease or injury.

“Durable medical equipment (DME)” means specialized equipment designed to stand repeated use, appropriate for home use, and used solely for medical purposes.

“Expendable medical supply” means a disposable article that is needed in quantity on a daily or monthly basis.

“Follow-up care” means the care which is related to the recovery from a specific procedure and which is considered part of the procedure's maximum reimbursement allowance, but does not include complications.

“Follow-up days” are the days of care following a surgical procedure which are included in the procedure's maximum reimbursement allowance amount, but which do not include complications. The follow-up day period begins on the day of the surgical procedure(s).

“Independent procedure” means a procedure that may be carried out by itself, completely separate and apart from the total service that usually accompanies it. 

“Inpatient services” means services rendered to a person who is admitted as an inpatient to a hospital.

“Medical record” means a record in which the medical service provider records the subjective findings, objective findings, diagnosis, treatment rendered, treatment plan, and return to work status and/or goals and impairment rating as applicable.

“Medical supply” means either a piece of durable medical equipment or an expendable medical supply.

“Observation services” means services rendered to a person who is designated or admitted as observation status.

“Operative report” means the practitioner's written description of the surgery and includes all of the following:

• A preoperative diagnosis;

• A postoperative diagnosis;

• A step-by-step description of the surgery;

• A description of any problems that occurred in surgery; and

• The condition of the patient upon leaving the operating room.

“Optometrist” means an individual licensed to practice optometry.

“Orthotic equipment” means an orthopedic apparatus designed to support, align, prevent, or correct deformities, or improve the function of a moveable body part.

“Orthotist” means a person skilled in the construction and application of orthotic equipment.

“Outpatient service” means services provided to patients at a time when they are not hospitalized as inpatients.

“Payer” means the employer or self-insured employed group, carrier, or third-party administrator (TPA) who pays the provider billings.

“Pharmacy” means the place where the science, art, and practice of preparing, preserving, compounding, dispensing, and giving appropriate instruction in the use of drugs is practiced.

“Physician Specialty”. The rules and reimbursement allowances in the Delaware Workers' Compensation Medical Fee Schedule do not address physician specialization within a specialty.  Payment is not based on the fact that a physician has elected to treat patients with a particular/specific problem. Reimbursement to qualified physicians is the same amount regardless of specialty.

“Procedure code” means a five-digit numerical sequence or a sequence containing an alpha character and preceded or followed by four digits, which identifies the service performed and billed.

“Prosthesis” means an artificial substitute for a missing body part.

“Prosthetist” means a person skilled in the construction and application of prostheses.

“Provider” means a facility, health care organization, or a practitioner who provides medical care or services.

“Secondary procedure” means a surgical procedure performed during the same operative session as the primary surgery but considered an independent procedure that may not be performed as part of the primary surgery.

4.18.2.1   Reimbursement for injections includes charges for the administration of the drug and the cost of the supplies to administer the drug. Medications are charged separately.

4.18.2.2   The description must include the name of the medication, strength, and dose injected.

4.18.2.3   When multiple drugs are administered from the same syringe, reimbursement will be for a single injection.

4.18.2.4   Reimbursement for anesthetic agents such as Xylocaine and Carbocaine, when used for infiltration, is included in the reimbursement for the procedure performed and will not be separately reimbursed.

4.18.2.5   Anesthetic agents for local infiltration must not be billed separately; this is included in the reimbursement for the procedure.

4.18.2.6   Reimbursement for intra-articular and intra-bursal injections (steroids and anesthetic agents) may be separately billed. The description must include the name of the medication, strength, and volume given.

4.18.3.3.1   Some of the procedures or services listed in the CPT codebook that are commonly arried out as an integral component of a total service or procedure have been identified by the inclusion of the term "separate procedure." The codes designated as "separate procedure" should not be reported in addition to the code for the total procedure or service of which it is consider an integral component. 

4.18.3.3.2  However, when a procedure or service that is designated as a "separate procedure" Is carried out independently or considered to be unrelated or distinct from other procedure/services provided at that time, it may be reported by itself, or in addition to other procedures/services by appending modifier 59 to the specific "separate procedure" code to indicate that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure. This may represent a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries).

4.18.3.6.1 Physician Supervision - Definition of Supervision The term "supervise," for billing purposes, encompasses the following supervision requirement:
Direct personal supervision in the office setting does not mean that the physician must be present in the same room with a PA or NP. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the PA or NP is performing the services. In this instance, reimbursement should be made at the normal physician payment level as if the physician had provided the service. If the PA or NP provides care to the injured worker and the supervising physician is not immediately available, the reimbursements will be at 80% of the fee schedule rate.

4.18.3.6.2  Billing for PA or NP Service. The physician must render the bill for care, with the ensuing payment for the PA or NP service made directly to the physician employer.

4.18.3.6.3  Management of a New or Established Patient with a New Workers' - Compensation Problem - If the physician supervises the physician assistant's or nurse practitioner's evaluation, payment should be made at the physician's normal Workers' Compensation level for PA or NP services rendered in an outpatient setting. Where on-site direct physician supervision is not available and the physician assistant or nurse practitioner providing patient care is only able to communicate with a physician supervisor by telephone or other effective means of communication, payment for this service should be made at 80% of the Physician Payment Schedule. Physician assistants and nurse practitioners acting in the capacity of an assistant at surgery will receive 20% percent of the total allowance for the surgical procedures. Payment will be made to the physician assistant's or nurse practitioner's employer (the physician).

4.18.3.6.4   Follow-up Care of an Existing Patient with a Compensable Problem. If the physician supervises the physician assistant's or nurse practitioner's evaluation, payment should be made at the physician's normal reimbursement level for the PA or NP services rendered in the outpatient setting.

4.18.3.6.5   Modifiers for Physician Assistant and Nurse Practitioner Services. When a physician assistant (PA) or nurse practitioner (NP) bills for services other than assistant at surgery, modifiers "PA" or "NP" are used. Modifier 83, AS, is used to identify assistant at surgery services provided by a physician assistant or nurse practitioner.

4.19.1.1  General Guidelines

The E/M section is divided into broad categories such as office visits, hospital visits, and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital visits (initial and subsequent). The subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes. This classification is important because the nature of a physician's work varies by type of service, place of service, and the injured employee's status.  Physicians should include CPT codes for specific performance of diagnostic tests/studies for which specific CPT codes are available. These CPT codes should be reported separately, in addition to the appropriate E/M code.

4.19.1.2  Definitions

Certain key words and phrases are used throughout the E/M section. The following definitions are intended to reduce the potential for differing interpretations and to increase the consistency of reporting by physicians in differing specialties.

4.19.1.2.1    New and Established Patient: Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is 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, with in the past three years.  An established patient is one who has received professional services from a physician or another physician of the same specialty who belongs to the same group practice, with the past three years.

4.19.1.2.2    On-Call or Substitute Physician: In the instance where a physician is on call for or is covering for the authorized treating physician, the injured employee's encounter will be classified as it would have been by the physician who is not available.

4.19.1.2.3    Emergency Situation: No distinction is made between new and established patients in the emergency room. Emergency room services should be reported for any patient (new or established) who presents for treatment in the emergency department.

4.19.1.2.4   Concurrent Care: Concurrent care is the provision of similar service (e.g., hospital visits) to the same patient by more than one physician on the same day. When concurrent care is provided, no special reporting is required.

4.19.1.2.5 Counseling: Counseling is a discussion with an injured employee and/or family concerning one or more of the following areas:

• Diagnostic results, impressions, and/or recommended diagnostic studies

• Prognosis

• Risks and benefits of management (treatment) options

• Instructions for management (treatment) and/or follow-up

• Importance of compliance with chosen management (treatment) options

• Risk factor reduction

• Injured employee and family education.

4.19.1.2.6 Consultations: As defined in the CPT book, consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source. Consultations are reimbursable only to physicians with the appropriate specialty for the services provided. A consulting physician shall only initiate diagnostic and/or therapeutic services with approval from the authorized treating physician. Following a consultation, if the consulting physician assumes responsibility for management of all or any part of the injured employee's condition(s), the injured employee becomes an "established patient" (rather than follow-up consultation) under the care of the consulting physician.

4.19.1.2.7 Time: The amount of time spent with a patient is a factor to be taken into consideration when selecting the appropriate E&M code. CPT guidelines are to be followed.

A modifier indicates that a service or procedure performed has been altered by some specific circumstance but has not changed its definition or code. The modifying circumstance shall be identified by the appropriate modifier following the procedure code. The two-digit modifier should be placed after the usual procedure number. If more than one modifier is used, place the "Multiple Modifiers" code 99 immediately after the procedure code. This indicates that one or more additional modifier codes will follow. Only certain modifiers in each of the categories (Evaluation and Management, Anesthesia, Surgery, Pathology/Laboratory, Radiology, General Medicine, and Physical Medicine) will be recognized for reimbursement purposes. It is understood that modifiers not only clarify the services performed, but that the fee may be adjusted accordingly based on the increase or decrease in service.

The modifiers listed below may differ from those published by the American Medical Association. Medical providers submitting workers' compensation billing shall use only the modifiers set out in the fee schedule. The following modifiers will be recognized for reimbursement by the fee schedule for Evaluation and Management (E/M) codes:

24 Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period: The physician may need to indicate that an E/M service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.

25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service. Note: This modifier is not used to report and E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician's election. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). When reporting a reduced service, it is expected that the billed amount will be reduced by the provider. The amount of the reduction is at the discretion of the provider, but should reflect a level of reimbursement commensurate with the actual work done.

53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the physician for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).

57 Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.

59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier available and use of modifier 59 best explains the circumstances should modifier 59 be used.

Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

4.20.1.1     The base units in this section have been determined on an entirely different basis from the relative values in other sections. A conversion factor applicable to this section is not applicable to any other section.

4.20.1.2       The American Society of Anesthesiologists' (ASA) Relative Value Guide™ 2008 is recognized as an appropriate assessment of current relative values for specific anesthesiology procedures. It is the basis for the assigned base units for CPT codes in the Anesthesia section of the Fee Schedule. As such, any changes to the base units in the subsequent versions of the ASA Relative Value Guide™ will be reflected under the base units for CPT codes in the Anesthesia section of the Fee Schedule will be updated accordingly.

4.20.1.3       Anesthesia services provided to employees pursuant to this chapter shall be equal to eighty-five percent (85%) of actual charges for such services as of October 31, 2006, subject to adjustment as provided in this subsection. Verification that such billing is performed in compliance with this subsection shall be provided by each hospital to the Office of Workers' Compensation within sixty (60) days of the completion and issuance of audited financial statements to the hospital by its independent financial auditors. Such verification shall be subject to further review or audit by the Department of Insurance. Reasonable costs of such review or audit for purposes of this section shall be reimbursed to the Department of Insurance by whose billing is audited.

4.20.1.4     The health care payment system as to Anesthesia will be adjusted yearly from the date the Health Care Advisory Panel recommended adoption of the fee schedule, November 14, 2007, and each year thereafter the Department of Labor shall make an automatic adjustment to the maximum payment for anesthesia treatment, procedure and/or service in effect in January of that year. The Department of Labor shall increase or decrease the maximum payment by the percentage change of increase or decrease in the Consumer Price Index--Urban, U.S. City Average, All Items, as published in the United States Bureau of Labor Statistics.

Base units are listed for most procedures. This value is determined by the complexity of the service and includes all usual anesthesia services except the time actively spent in anesthesia care and the modifying factors. The base units include preoperative and postoperative visits, the administration of fluids and/or blood incident to the anesthesia care, and interpretation of noninvasive monitoring (ECG, temperature, blood pressure, oximetry, and other usual monitoring procedures). The basic anesthesia unit includes the routine follow-up care and observation (including recovery room observation and monitoring). When multiple surgical procedures are performed during the same period of anesthesia, only the highest base unit allowance of the various surgical procedures will be used.

Time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area. Time ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. The anesthesia time units will be calculated in 15-minute intervals, or portions thereof, equaling one (1) time unit. No additional time units are allowed for recovery room time and monitoring once the patient has been safely turned over to the recovery room staff.

4.20.4.1     Physical Status Modifiers

Physical status modifiers are represented by the initial letter P followed by a single digit from one (1) to six (6) defined below:

Status Description Base Units

• P1 A normal healthy patient 0

• P2 A patient with mild systemic disease 0

• P3 A patient with severe systemic disease 1

• P4 A patient with severe systemic disease that is a constant threat to life 2

• P5 A moribund patient who is not expected to survive without the operation 3

• P6 A patient declared brain-dead whose organs are being removed for donor purposes 0

The above six levels are consistent with the American Society of Anesthesiologists' (ASA) ranking of patient physical status. Physical status is included in the CPT book to distinguish between various levels of complexity of the anesthesia service provided.

4.20.4.2     Qualifying Circumstances

4.20.4.2.1     More than one qualifying circumstance may be selected. Many anesthesia  services are provided under particularly difficult circumstances, depending on factors such as extraordinary condition of patient, notable operative conditions, and/or unusual risk factors. This section includes a list of important qualifying circumstances that significantly affect the character of the anesthesia service provided. These procedures would not be reported alone but would be reported as additional procedure numbers qualifying an anesthesia procedure or service.

99100 Anesthesia for patient of extreme age, younger than one year and older than seventy (List separately in addition to code for primary anesthesia procedure)1

99116 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)5

99135 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure)5

99140 Anesthesia complicated by emergency conditions (specify conditions) (List separately in addition to code for primary anesthesia procedure) (An emergency is defined as existing when delay in treatment of a patient would lead to a significant increase in the threat to life or body part.)2

4.20.4.2.2       Payers must utilize their medical consultants when there is a question regarding modifiers and/or special circumstances for anesthesia charges.

Monitored anesthesia care occurs when the attending physician requests that an anesthesiologist be present during a procedure. This may be to insure compliance with accepted procedures of the facility. Monitored anesthesia care includes pre-anesthesia exam and evaluation of the patient. The anesthesiologist must participate or provide medical direction for the plan of care. The anesthesiologist, resident, or nurse anesthetist must be in continuous physical presence and provide diagnosis and treatment of emergencies. This will also include noninvasive monitoring of cardiocirculatory and respiratory systems with administration of oxygen and/or intravenous administration of medications. Reimbursement will be the same as if general anesthesia had been administered (time units + base units).

4.20.6.1     Criteria for Reimbursement

Anesthesia services may be billed for any one of the three following circumstances:

4.20.6.1.1       An anesthesiologist provides total and individual anesthesia service.

4.20.6.1.2       An anesthesiologist directs a CRNA or AA.

4.20.6.1.3       Anesthesia provided by a CRNA or AA working independent of an  anesthesiologist's supervision is covered under the following conditions:

• The service falls within the CRNA's or AA's scope of practice and scope of license as defined by law.

• The service is supervised by a licensed health care provider who has prescriptive authority in accordance with the clinical privileges individually granted by the hospital or other health care organization.

4.20.6.2   Reimbursement

4.20.6.2.1     The maximum reimbursement allowance for anesthesia is calculated by adding the base unit value, the number of time units, any applicable modifier and/or unusual circumstances units, and multiplying the sum by a dollar amount (conversion factor) allowed per unit.

4.20.6.2.2     Reimbursement includes the usual pre- and postoperative visits, the care by the anesthesiologist during surgery, the administration of fluids and/or blood, and the usual monitoring services. Unusual forms of monitoring, such as central venous, intraarterial, and Swan-Ganz monitoring, may be reimbursed separately.

4.20.6.2.3       When an unlisted service or procedure is provided, the value should be  substantiated with a report. Unlisted services are identified in this Fee Schedule as by report.

4.20.6.2.4       When it is necessary to have a second anesthesiologist, the necessity should be substantiated. The second anesthesiologist will receive five base units + time units (calculation of total anesthesia value).

4.20.6.2.5       Payment for covered anesthesia services is as follows:

• When the anesthesiologist provides an anesthesia service directly, payment will be made in accordance with the billing reimbursement rules of this Fee Schedule.

• When an anesthesiologist provides medical direction to the CRNA or AA providing the anesthesia service, then the reimbursement will be divided between the two of them at fifty percent (50%).

• When the CRNA or AA provides the anesthesia service directly, then payment will be the lesser of the billed charge or eighty percent (85%) of the maximum allowable listed in the Fee Schedule for that procedure.

4.20.6.2.6       Anesthesiologists, CRNAs, and AAs must bill their services with the appropriate modifiers to indicate which one provided the service. Bills NOT properly coded may cause a delay or error in reimbursement by the payer. Application of the appropriate modifier to the bill for service is the responsibility of the provider, regardless of the place of service. Modifiers are as follows:

AA Anesthesiologist services performed personally by an anesthesiologist

AD Medical supervision by a physician: more than four concurrent anesthesia

procedures

QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals (CRNA or AA) by an anesthesiologist

QX CRNA or AA service: with medical direction by an anesthesiologist

QY Medical direction of one certified registered nurse anesthetist (CRNA or AA) by an anesthesiologist

QZ CRNA service: without medical direction by an anesthesiologist

All anesthesia services are reported by using the anesthesia five-digit procedure codes. The basic value for most procedures may be modified under certain circumstances as listed below. When applicable, the modifying circumstances should be identified by the addition of the appropriate modifier (including the hyphen) after the usual anesthesia code. Certain modifiers require a special report for clarification of services provided.

Modifiers commonly used in anesthesia are as follows:

22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number. A report may also be appropriate.

23 Unusual Anesthesia: Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding modifier 23 to the procedure code of the basic service.

32 Mandated Services: Services related to mandated consultation and/or related services (eg, third-party payer, governmental, legislative, or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.

53 Discontinued Procedure: Under certain circumstances the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the wellbeing of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the physician for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite.

59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier available and use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service with a non-E/M service with a non-E/M service performed on the same date, see modifier 25.

AA Anesthesia Services Performed Personally by the Anesthesiologist: Report modifier AA when the anesthesia services are personally performed by an anesthesiologist.

AD Medical Supervision by a Physician: More Than Four Concurrent Anesthesia Procedures: Report modifier AD when the anesthesiologist supervises more than four concurrent anesthesia procedures.

QK Medical Direction of Two, Three, or Four Concurrent Anesthesia Procedures InvolvingQualified Individuals: Report modifier QK when the anesthesiologist supervises two, three, or four concurrent anesthesia procedures.

QX CRNA or AA Service with Medical Direction by a Physician: Regional or general anesthesia provided by the CRNA or AA with medical direction by a physician may be reported by adding modifier QX.

QY Medical Supervision by Physician of One CRNA or AA: Report modifier QY when the anesthesiologist supervises one CRNA or AA.

QZ CRNA or AA Service without Medical Direction by a Physician: Regional or general anesthesia provided by the CRNA or AA without medical direction by a physician may be reported by adding modifier QZ.

4.20.8.1       CPT Codes that Include Moderate (Conscious) Sedation - Moderate (conscious) sedation is a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.  No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

4.20.8.2     Moderate sedation does not include minimal sedation (anxiolysis), deep sedation or  monitored anesthesia care (00100-01999).

4.20.8.3     When providing moderate sedation, the following services are included and NOT reported separately:

4.20.8.3.1       Assessment of the patient (not included in intraservice time);

4.20.8.3.2       Establishment IV access and fluids to maintain patency, when performed;

4.20.8.3.3       Administration of agent(s);

4.20.8.3.4       Maintenance of sedation;

4.20.8.3.5       Monitoring of oxygen saturation, heart rate and blood pressure; and

4.20.8.3.6       Recovery (not included in intraservice time).

4.20.8.4       Intraservice time starts with the administration of the sedation agent(s), require continuous f ace-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.

4.20.8.5       Do not report 99143-99150 in conjunction with 94760-94762.

4.20.8.6       Do not report 99143-99145 in conjunction with codes listed in Appendix G. Do not report 99148-99150 in conjunction with codes listed in Appendix G when performed in the nonfacility setting.

Appendix G from the American Medical Association's 2009 CPT Codes

Summary of CPT Codes That Include Moderate (Conscious) Sedation

Note: Because these codes include moderate sedation, it is not appropriate for the same physician to report boththe service and the sedation codes 99143-99145. If a physician other than the treating physician provides moderate sedation in a facility for one of the procedures on this list, the other physician should report codes 99148-99150. If this arrangement occurs in the provider's office, these codes would not be reported.CPT codes 00100-01999 can be used to report associated anesthesia services regardless of whether theprocedure is on this list.

19298 20982 22526 22527 31615 31620 31622 31623 31624 31625

31628 31629 31635 31645 31646 31656 31725 32201 32550 32551

33010 33011 33206 33207 33208 33210 33211 33212 33213 33214

33216 33217 33218 33220 33222 33223 33233 33234 33235 33240

33241 33244 33249 35470 35471 35472 35473 35474 35475 35476

36555 36557 36558 36560 36561 36563 36565 36566 36568 36570

36571 36576 36578 36581 36582 36583 36585 36590 36870 37184

37185 37186 37187 37188 37203 37210 37215 37216 43200 43201

43202 43204 43205 43215 43216 43217 43219 43220 43226 43227

43228 43231 43232 43234 43235 43236 43237 43238 43239 43240

43241 43242 43243 43244 43245 43246 43247 43248 43249 43250

43251 43255 43256 43257 43258 43259 43260 43261 43262 43263

43264 43265 43267 43268 43269 43271 43272 43273 43453 43456

43458 44360 44361 44363 44364 44365 44366 44369 44370 44372

44373 44376 44377 44378 44379 44380 44382 44383 44385 44386

44388 44389 44390 44391 44392 44393 44394 44397 44500 44901

45303 45305 45307 45308 45309 45315 45317 45320 45321 45327

45332 45333 45334 45335 45337 45338 45339 45340 45341 45342

45345 45355 45378 45379 45380 45381 45382 45383 45384 45385

45386 45387 45391 45392 47011 48511 49021 49041 49061 49440

49441 49442 49446 50021 50382 50384 50385 50386 50387 50592

50593 58823 66720 69300 77600 77605 77610 77615 92953 92960

92961 92973 92974 92975 92978 92979 92980 92981 92982 92984

92986 92987 92995 92996 93312 93313 93314 93315 93316 93317

93318 93501 93505 93508 93510 93511 93514 93524 93526 93527

93528 93529 93530 93539 93540 93541 93542 93543 93544 93545

93555 93556 93561 93562 93571 93572 93609 93613 93615 93616

93618 93619 93620 93621 93622 93624 93640 93641 93642 93650

93651 93652

4.20.8.7       When a second physician other than the healthcare professional performing the diagnostic or therapeutic services provides moderate sedation in the facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility) for the procedures listed in G, the second physician reports 99148-99150. However, for the circumstance in which these services are performed by the second physician in the non-facility setting (e.g., physician office, freestanding imaging center), codes 99148-99150 are not reported.

4.20.8.8       Some CPT codes include moderate (conscious) sedation as an inherent component of the procedure. These are identified in the CPT book with a K symbol. Because these services include moderate (conscious) sedation, special rules apply when reporting the moderate (conscious) sedation CPT codes 99143–99150. Moderate (conscious) sedation services provided by the same physician performing the diagnostic or therapeutic service that the sedation supports and requiring the presence of a second independent trained observer for monitoring purposes (CPT codes 99143–99145) may not be reported in conjunction with CPT codes identified with a K symbol and listed in Appendix G.

4.20.8.9       In rare instances a second physician other than the physician performing the diagnostic or therapeutic service may be required to provide the moderate (conscious) sedation service (CPT codes 99148–99150). When these sedation services are performed in a facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility), the second physician may report the moderate (conscious) sedation service with CPT code(s) 99148–99150 in conjunction with CPT codes identified with a K symbol and listed in Appendix G. However, when the second physician performs the moderate (conscious) sedation services in a non facility setting (e.g., physician office, freestanding imaging center) CPT code(s) 99148–99150 should not be reported separately and are not in Delaware Workers’ Compensation Medical Fee Schedule. CPT code(s) 99148– 99150 should not be reported separately and are not reimbursable when performed in conjunction with CPT codes identified with a K symbol and listed in Appendix G. See Appendix G in CPT 2008 for a list of CPT codes that includes moderate (conscious)sedation.

4.21.1.1     Global Reimbursement

The reimbursement allowances for surgical procedures are based on a global reimbursement concept that covers performing the basic service and the normal range of care required after surgery.

4.21.1.1.1         Global reimbursement includes:

• The operation per se

• Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia

• Immediate postoperative care, including dictating operative notes, talking with the family and other physicians

• Writing orders

• Evaluating the patient in the post anesthesia recovery area

• Normal, uncomplicated follow-up care for the time periods indicated in the follow-up days (FUD) column to the right of each procedure code. The number in that column establishes the days during which no additional reimbursement is allowed for the usual care provided following surgery, absent complications or unusual circumstances.

• The maximum reimbursement allowances cover all normal postoperative care, including the removal of sutures by the surgeon or associate. Follow-up days are specified by procedure.

4.21.1.1.2       Follow-up days listed are for 0, 10, or 90 days and are listed in the Fee Schedule as 000, 010, or 090.

4.21.1.2     Follow-up Care for Diagnostic Procedures

Follow-up care for diagnostic procedures (e.g., endoscopy, arthroscopy, injection procedures for radiography) includes only the care related to recovery from the diagnostic procedure itself. Care of the condition for which the diagnostic procedure was performed or of other concomitant conditions is not included and may be listed separately.

4.21.1.3     Follow-up Care for Therapeutic Surgical Procedures

Follow-up care for therapeutic surgical procedures includes only care that is usually part of the surgical procedure. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be reported separately.

4.21.1.4       Separate Procedures

Some of the procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term “separate procedure”. The codes designated as “separate procedure” should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.

4.21.1.5     Biopsy Procedures

A biopsy of the skin and another surgical procedure performed on the same lesion on the same day must be billed as one procedure.

4.21.1.6     Repair of Nerves, Blood Vessels, and Tendons with Wound Repairs

The repair of nerves, blood vessels, and tendons is usually reported under the appropriate system. The repair of associated wounds is included in the primary procedure unless it qualifies as a complex wound, in which case modifier 51 may be applied. Simple exploration of nerves, blood vessels, and tendons exposed in an open wound is also considered part of the essential treatment of the wound closure and is not a separate procedure unless appreciable dissection is required.

4.21.1.7     Suture Removal

Billing for suture removal by the operating surgeon is not appropriate as this is considered part of the global fee.

4.21.1.8     Supplies and Materials

Supplies and materials provided by the physician (e.g., sterile trays/drugs) over and above those usually included with the office visit may be listed separately using CPT code 99070 or specific HCPCS Level II codes.

4.21.1.9     Implants

Implants of any type are to be billed as part of the hospital or ASC billing. Bone morphogenetic protein is an FDA approved biologic fusion and fracture healing aid. Its use in spine and fracture surgery represents the standard of care in our community, and in both on-label and off-label applications is accepted and to be reimbursed to the facility providing the implant, at rates consistent with implant payment rates determined under the respective ASC and hospital reimbursement guidelines.

4.21.1.10 Aspirations and Injections

Puncture of a cavity or joint for aspiration followed by injection of a therapeutic agent is one procedure and should be billed as such.

4.21.1.11 Surgical Assistant

4.21.1.11.1 Physician surgical assistant — For the purpose of reimbursement, a physician  who assists at surgery is reimbursed as a surgical assistant. Assistant surgeons should use modifier 80 and are allowed twenty percent (20%) of the maximum reimbursement allowance (MRA) for the procedure(s).

4.21.1.11.2   Registered Nurse Surgical Assistant or Physician Assistant

• A physician assistant (PA), or registered nurses (NP) who have completed an approved first assistant training course, may be allowed a fee when assisting a surgeon in the operating room (O.R.).

• The maximum reimbursement allowance for the physician assistant or the registered nurse first assistant (RNFA) is twenty percent (20%) of the surgeon’s fee for the procedure(s) performed.

• Under no circumstances will a fee be allowed for an assistant surgeon and a physician assistant or RNFA at the same surgical encounter.

• Registered nurses on staff in the O.R. of a hospital, clinic, or outpatient surgery center do not qualify for reimbursement as an RNFA.

4.21.1.12 Operative Reports

An operative report must be submitted to the payer before reimbursement can be made for the surgeon’s or assistant surgeon’s services.

4.21.1.13 Needle Procedures

Needle procedures (lumbar puncture, thoracentesis, jugular or femoral taps, etc.) should be billed in addition to the medical care on the same day.

4.21.1.14 Therapeutic Procedures

Therapeutic procedures (injecting into cavities, nerve blocks, etc.) (CPT codes 20526– 20610, 64400, and 64450) may be billed in addition to the medical care for a new patient. (Use appropriate level of service plus injection.) In follow-up cases for additional therapeutic injections and/or aspirations, an office visit is only indicated if it is necessary to re-evaluate the patient. In this case, a minimal visit may be listed in addition to the injection. Documentation supporting the office visit charge must be submitted with the bill to the payer. This is clarified in the treatment guidelines in a more specific manner. Trigger point injection is considered one procedure and reimbursed as such regardless of the number of injection sites. Two codes are available for reporting trigger point injections. Use 20552 for injection(s) of single or multiple trigger point(s) in one or two muscles or 20553 when three or more muscles are involved.

4.21.1.15 Anesthesia by Surgeon

In certain circumstances it may be appropriate for the attending surgeon to provide regional or general anesthesia. Anesthesia by the surgeon is considered to be more than local or digital anesthesia. Identify this service by adding modifier 47 to the surgical procedure code.

4.21.1.16 Therapeutic/Diagnostic Injections

Injections are considered incidental to the procedure when performed with a related invasive procedure.

4.21.1.17 Intervertebral Biomechanical Device(s) and Use of Code 22851

Code 22851 describes the application of an intervertebral biomechanical device to a vertebral defect or interspace. Code 22851 should be listed in conjunction with a primary procedure without the use of modifier 51. The use of 22851 is limited to one instance per single interspace or single vertebral defect regardless of the number of devices applied and infers additional qualifying training, experience, sizing, and/or use of special surgical appliances to insert the biomechanical device. Qualifying devices include manufactured synthetic or allograft biomechanical devices, or methyl methacrylate constructs, and are not dependant on a specific manufacturer, shape, or material of which it is constructed. Qualifying devices are machine cut to specific dimensions for precise application to an intervertebral defect. (For example, the use of code 22851 would be appropriate during a cervical arthrodesis (22554) when applying a synthetic alloy cage, a threaded bone dowel, or a machine cut hexahedron cortical, cancellous, or corticocancellous allograft biomechanical device. Surgeons utilizing generic non-machined bony allografts or autografts are referred to code sets 20930–20931, 20936–20938 respectively.)

4.21.1.18 Spinal and Cranial Services Require Additional Surgeon

Certain spinal and cranial procedures require the services of an additional surgeon of a different specialty to gain exposure to the spine and brain. These typically are vascular, thoracic and ENT. The surgical exposure portion of these procedures will be billed, dictated and followed separately by the exposure surgeon for their portion of the procedure. Since the exposure surgeon is required based upon the type of surgery recommended by the treating surgeon, it is intended that an approval for the primary procedure includes the approach, and no separate pre-approval or pre-authorization is required. The exposure surgeon is bound by the fee schedule regarding reimbursementand all other rules delineated above.

For purposes of this section of the Fee Schedule, "ambulatory surgery center" means an establishment with an organized medical staff of physicians; with permanent facilities that are equipped and operated primarily for the purpose of performing surgical procedures; with continuous physicians and registered nurses on site when the facility is open. An ambulatory surgery center may be a freestanding facility or may be attached to a hospital facility. For purposes of Workers' Compensation reimbursement to ASCs, the facility must be an approved Medicare ASC, or certified by AAA.

4.22.2.1       Facility fees for ambulatory surgery must be billed on the UB-04 form.

4.22.2.2       The CPT/HCPCS code(s) of the procedure(s) performed determines the reimbursement for the facility fee. Report all procedures performed.

4.22.2.3       The payment rate for an ASC surgical procedure includes all facility services directly related to the procedure performed on the day of surgery. Facility services include:

• Nursing and technician services

• Use of the facility

• Drugs, biologicals, surgical dressings, splints, casts and equipment directly related to

the provision of the surgical procedure

• Materials for anesthesia

• Administration, record keeping and housekeeping items and services.

4.22.2.4     Disposable injection supplies under $75 are included in the facility fee. Those over $75 are reimbursed at 85% of the ASC fee for the item.

4.22.2.5     Separate payment is not made for the following services that are directly related to the  surgery:

• Pharmacy

• Medical/surgical supplies other than 5 and 6 above in this section,

• Sterile supplies

• Operating room services

• Ambulatory surgical care

• Recovery room

• Treatment or Observation room

4.22.2.6     Facility fees do not include physician services, x-rays, diagnostic procedures, laboratory procedures, CRNA or anesthesia physician services, prosthetic devices, ambulance services, braces, artificial limbs or DME for use in the patient's home. These items will be reimbursed according to Fee Schedule.

25 Significant, Separately Identifiable Evaluation and Management Service by the Same

Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service provided above or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for I instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service on the same date. This circumstance may be reported adding modifier 25 to the appropriate level E/M code. Note: This modifier is not used to report and E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

27 Multiple Outpatient Hospital E/M Encounters on the Same Date: For hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level outpatient and/or emergency department E/M code(s). This modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than one (multiple) outpatient hospital setting(s) (e.g., hospital emergency department, clinic).

Note: This modifier is not to be used for physician reporting of multiple E/M services performed by the same physician on the same date. For physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient setting(s) (e.g., hospital emergency department, clinic), see Evaluation and Management, Emergency Department, or Preventive Medicine Services codes.

50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding modifier 50 to the appropriate five digit code.

52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).

58 Staged or Related Procedure or Service by the Same Physician During the PostoperativePeriod: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure.

Note: For treatment of a problem that requires a return to the operating or procedure room (e.g., unanticipated clinical condition), see modifier 78.

59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier available and use of modifier 59 best explains the circumstances should modifier 59 be used.

Note: Modifier 59 should not be appended to an E/M service with a non-E/M service with a non-E/ M service performed on the same date, see modifier 25.

73 Discontinued Out-Patient Hospital/ Ambulatory Surgery Center (ASC) Procedure Prior tothe Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of modifier 73.

Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

74 Discontinued Out-Patient Hospital/ Ambulatory Surgery Center (ASC) Procedure AfterAdministration of Anesthesia: Due to extenuating circumstances or those that threaten the wellbeing of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74.

Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

76 Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure/service.

77 Repeat Procedure by Another Physician: The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure/service.

78 Unplanned Return to the Operating/Procedure Room by the Same Physician FollowingInitial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and require the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.)

79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period:The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.)

91 Repeat Clinical Diagnostic Laboratory Test: In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91.

Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used forlaboratory test(s) performed more than once on the same day on the same patient.

Multiple procedures performed during the same operative session at the same operative site are reimbursed as follows:

• One hundred percent (100%) of the allowable fee for the primary procedure

• One hundred percent (100%) of the allowable fee for the second and subsequent procedures

Physicians and staff are sometimes confused by the definition of bilateral. Bilateral procedures are identical procedures (i.e., use the same CPT code) performed on the same anatomic site but on opposite sides of the body.

• The primary procedure, which is defined as the procedure with the highest RVU, must be billed with the applicable CPT code.

• The second or lesser or additional procedure(s) may be billed by adding modifier 51 to the codes unless the procedure(s) is exempt from modifier 51 or qualifies as an addoncode.

Wound repairs are classified as simple, intermediate, or complex.

4.24.1.1   Simple repair. Simple repair is repair of superficial wounds involving primarily epidermis and dermis or subcutaneous tissues without significant involvement of deeper structures and simple one layer closure/suturing. This includes local anesthesia and chemical or electro cauterization of wounds not closed.

4.24.1.2     Intermediate repair. Intermediate repair is repair of wounds that requires layered closure of one or more of the subcutaneous tissues and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily contaminated wounds that require extensive cleaning or removal of particulate matter also constitutes intermediate repair.

4.24.1.3   Complex repair. Complex repair is repair of wounds requiring more than layered closure, scar revision, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. It may include creation of the defect and necessary preparation for repairs or the debridement and repair of complicated lacerationsor avulsions.

The following instructions are for reporting services at the time of the wound repair:

4.24.2.1     The repaired wound(s) should be measured and recorded in centimeters, whether curved, angular, or stellate.

4.24.2.2     When multiple wounds are repaired, add together the lengths of those in the same classification (see above) and anatomical grouping and report as a single item. When more than one classification of wound is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure using modifier 51.

4.24.2.3   Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure (extensive debridement of soft tissue and/or bone).

4.24.2.4     Report involvement of nerves, blood vessels, and tendons under the appropriate system (nervous, musculoskeletal, etc.) for repair. The repair of these wounds is included in the fee for the primary procedure unless it qualifies as a complex wound, in which casemodifier 51 applies.

4.24.2.5     Simple ligation of vessels in an open wound is considered part of any wound closure, as is simple exploration of nerves, blood vessels, or tendons.

4.24.2.6     Adjacent tissue transfers, flaps and grafts include such procedures as Z-plasty, W- plasty, V-4-plasty or rotation flaps. Reimbursement is based on the size of the defect. Closing the donor site with a skin graft is considered an additional procedure and will be reimbursed in addition to the primary procedure. Excision of a lesion prior to repair by adjacent tissue transfer is considered “bundled” into the tissue transfer procedure and is not reimbursed separately.

4.24.2.7     Wound exploration codes should not be billed with codes that specifically describe a repair to major structure or major vessel. The specific repair code supersedes the use of awound exploration code.

This applies to severe muscle sprains or strains that require casting or strapping.

4.25.1.1     Initial (new patient) treatment for soft tissue injuries must be billed under the appropriate office visit code.

4.25.1.2     When a cast or strapping is applied during an initial visit, supplies and materials (e.g., stockinet, plaster, fiberglass, ace bandages) may be itemized and billed separately using the appropriate HCPCS Level II code.

4.25.1.3     When initial casting and/or strapping is applied for the first time during an established patient visit, reimbursement may be made for the itemized supplies and materials in addition to the appropriate established patient visit.

4.25.1.4     Replacement casts or strapping provided during a follow-up visit (established patient) includes reimbursement for the replacement service as well as the removal of casts, splints, or strapping. If a cast is damaged or destroyed and must be replaced, the supplies and the office visit are reimbursed. Office notes should substantiate medical necessity of the visit. Cast supplies may be billed using the appropriate HCPCS Level II code and reimbursed separately.

4.25.2.1     Fracture care is a global service. It includes the examination, restoration or stabilization of the fracture, application of the first cast, and cast removal. Casting material is not considered part of the global package and may be reimbursed separately. It is inappropriate to bill an office visit since the reason for the encounter is for fracture care. However, if the patient requires surgical intervention, additional reimbursement can be made for the appropriate E/M code to properly evaluate the patient for surgery. Use modifier 57 with the E/M code.

4.25.2.2     Reimbursement for fracture care includes the application and removal of the first cast or traction device only. Replacement casting during the period of follow-up care is reimbursed separately.

4.25.2.3     The phrase “with manipulation” describes reduction of a fracture.

4.25.2.4     Re-reduction of a fracture performed by the primary physician may be identified by the addition of modifier 76 to the usual procedure code to indicate “repeat procedure” by the same physician.

4.25.2.5     The term “complicated” appears in some musculoskeletal code descriptions. It implies an infection occurred or the surgery took longer than usual. Be sure the medical recorddocumentation supports the “complicated” descriptor to justify reimbursement.

Note: Surgical arthroscopy always includes a diagnostic arthroscopy. Only in the most unusual case is an increased fee justified because of increased complexity of the intra-articular surgery performed.

4.25.3.1    Diagnostic arthroscopy should be billed at fifty percent (50%) when followed by open surgery.

4.25.3.2     Diagnostic arthroscopy is not billed when followed by arthroscopic surgery.

4.25.3.3     If there are only minor findings that do not confirm a significant preoperative diagnosis, the procedure should be billed as a diagnostic arthroscopy.

Many revisions have occurred in CPT coding for arthrodesis procedures. References to bone grafting and fixation are now procedures which are listed and reimbursed separately from the arthrodesis codes. To help alleviate any misunderstanding about when to code a discectomy in addition to an arthrodesis, the statement “including minimal discectomy” to prepare interspace has been added to the anterior interbody technique. If the disk is removed for decompression of the spinal cord, the decompression should be coded and reimbursed separately.

The following criteria is established for the medically accepted standard of care when determining applicability for the use of an external spinal stimulator.

4.25.5.1     Patient has had a previously failed spinal fusion, and/or

4.25.5.2     Patient is scheduled for revision or repair of pseudo arthrosis, and/or

4.25.5.3     The patient smokes greater than a pack of cigarettes per day and is scheduled for spinal fusion

4.25.5.4     The patient is metabolically in poor health, with other medical comorbidities such as diabetes, Rheumatoid arthritis, lupus or other illnesses requiring oral steroids or cytotoxic medications.

4.25.5.5     Pre certification is required for use of the external spinal stimulator if the planned use falls outside the above indications.

The following intra operative services are included in the global service package for carpal tunnel release and should not be reported separately and do not warrant additional reimbursement:

• Surgical approach

• Isolation of neurovascular structures

• Video imaging

• Stimulation of nerves for identification

• Application of dressing, splint, or cast

• Tenolysis of flexor tendons