Tuesday, July 5, 2016

Payment for Bundled and multiple surgery in ASC

Bundled services

• FCHP only reimburses the more “intensive” CPT code when a procedure is considered to be part of a more comprehensive procedure or a single more comprehensive CPT code more accurately describes a group of procedures.

Multiple surgical services

• FCHP closely aligns with CMS guidelines in determining which procedure codes are subject to multiple procedure reduction. Reference the CMS Web site for information on specific procedure codes.

• When multiple surgical services are performed at the same session, the procedure with the highest intensity is reimbursed at full payment; when allowed, others are reimbursed at 50% of the contracted fee or pursuant to contractual agreement.

• No additional payment is made beyond five services.

Payments are subject to post-payment audits and retraction of overpayments.

Referral/notification/prior authorization requirements

Summit ElderCare requires prior authorization for all non-emergency outside services. Please contact the referring Summit ElderCare PACE site for assistance. NaviCareSM requires that all non-emergency services be authorized in advance. Please contact an Enrollee Service Representative at (877) 700-6996 for assistance. Prior authorization is required for select ambulatory/same day surgical procedures and/or services.

The ordering physician is required to obtain prior authorization for:

• Unlisted CPT codes.

• The applicable codes found on the List of Procedures Requiring Prior Authorization located in the Managing Patient Care section of the Provider Manual under PCP Referral and Plan Prior Authorization Process.

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