36.4.47.8 Global FeesThe Texas Medicaid Program reimburses surgeons, assistant surgeons, and anesthesiologists based on a global fee concept. The global fee concept means that the fee paid for the surgical procedure includes varying preoperative and postoperative care based on the complexity of the procedure. No distinction is made between emergency and nonemergency procedures because the required package of services is the same. Surgical procedures are reimbursed as a comprehensive global fee for the performance of the procedure. The method of accomplishing the surgical procedure is the election of the surgeon, who may elect to incorporate new technology in the procedure because it offers advantages. However, the global fee remains the fee for the procedure, with additional payment not afforded because of surgeon preference as to the technology selected for completion of the procedure. Separate charges for the use of special equipment or other modifications during surgery are denied. Consultations or visits denied within the pre-care of a surgery may be considered an appeal with documentation establishing the medical necessity for exceeding the global surgical fee limitations. The reimbursement for minor surgeries (for example, elbow arthroscopy, conjunctiva biopsy) include all routine care related to the surgery three days preoperatively and seven days postoperatively. Major surgeries (for example, gastrostomy, hysterectomy, and cataract extraction) include all routine care pertaining to the surgery three days preoperatively including admissions and consultations and all routine postoperative care for six weeks in any POS. Extensive surgical procedures (for example, total hip replacement) include all routine care related to the surgical procedure three days preoperatively and for a period of 180 days postoperatively regardless of the POS of the pre and postoperative procedures. Simple diagnostic (for example, paracentesis) and minor surgical procedures (for example, repair of a superficial wound up to 2.5 cm) do not include any preoperative or postoperative care restrictions. If the procedure is performed in the office or home, refer to "Office or Other Outpatient Services" . If the simple diagnostic procedure is performed in an inpatient hospital setting, a visit is not paid on the same day unless it is for a distinctly separate diagnosis. Modifier 25 may be used to describe circumstances in which an office visit was provided at the same time as other separately identifiable services (e.g., THSteps visits, minor procedure). Both services must be documented as distinct and documentation must be maintained in the medical record and made available to the Texas Medicaid Program upon request. This modifier may be appended to the evaluation code when the services rendered meet the following conditions:
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• Postoperative complications necessitating readmission to the hospital during the postoperative package of service (that exceeds 72 hours of observation for a complication of the surgical procedure) may be reimbursed outside the package of service on appeal to the TMHP Medical Director. Documentation of the medical appropriateness of the protracted medical stay is required with submission of the appeal. All supplies (trays, dressings, casting and splinting supplies, and local anesthetics) are considered part of the surgical procedure and should not be billed separately to Medicaid or the client. Refer to: "Paper Appeals" for information about submitting appeals. |
Are distinct.
