Sunday, April 10, 2016

Payment policy for Global Surgical services

Global Surgical Services

Services provided by another physician and/or health care professionals within the same group reporting the same Federal Tax Identification number will be included in the global surgical package reimbursement and not considered separately reimbursable.

Harvard Pilgrim reimburses surgical services at a single all-inclusive (global) contract rate. Payment includes:

• Pre-operative visits within 24 hours prior to a major surgery and on the same day a major or minor surgery is performed.
• Intra-operative services that are a usual and medically necessary part of the surgical procedure.
• Complications; all additional medical or surgical services rendered by the surgeon within the global period due to complications that do not require a re-operation or return trip to the operating room.
• Services for post-operative pain management rendered by the surgeon.
• Anesthesia services rendered by the surgeon.
• Miscellaneous services, such as:
- Dressing changes
- Other routine post-operative services
- Removal of or change of, tracheostomy tubes
- Removal of sutures, lines, wires and splints, etc.
- Removal of urinary catheters, routine IV lines
• All post-operative visits, both inpatient and outpatient, within the global period related to the surgical procedure.
• Harvard Pilgrim follows the global period indicator as designated by CMS of 0, 10, 90 or YYY for each Procedure code.


Surgical Services Reimbursed Outside of the Global Rate When Billed With Appropriate Modifier


• Services rendered for post-operative complications requiring a return trip to the operating room.
• Services of another physician, unless the physician is part of the same specialty group practice.
• If one physician performs the surgery but a different physician renders post-operative care, each service is reimbursed
separately.
• For surgical procedures with zero days assigned as a global period, post-operative visits are reimbursed
• Visits unrelated to the diagnosis (see below for same day significant E&M with global day service)
- Treatment for an underlying condition
- An added course of treatment not related to the surgery
• Diagnostic tests and procedures, including radiological procedures

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