Postoperative Visits

For Major Surgical Procedures

HMSA considers a major surgical procedure as a procedure that is performed in an operating room, usually under general anesthesia. A global surgery fee is paid for all necessary services done before, during, and after a major surgical procedure.

Postoperative services are inpatient or outpatient services for an established patient that are directly related to a surgical procedure. Postoperative services for a major surgical procedure include postoperative evaluations. These services can be provided by the surgeon or any physician designated by the surgeon, generally up to 90 days after the date of the surgery (postoperative period. Postoperative services performed in conjunction with minor surgery and endoscopic procedures can be provided in a postoperative period of up to 10 days. HMSA's 10- and 90-day postoperative periods are consistent with Medicare guidelines.

HMSA's global surgery fee includes payment for postoperative services that include:

• Evaluations.
• Dressing changes.
• Local wound care.
• Removal of operative packs, cutaneous sutures, staples, lines, wires, tubes, drains, casts, and splints.
• Insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, and nasogastric and rectal tubes.
• Change and removal of tracheostomy tubes.

When these services are performed by the surgeon, they are not eligible for payment if they are billed separately from the surgical procedure.

The following services may be reviewed on an individual basis for payment separate from the global surgical fee:

• Any service for a problem unrelated to the diagnosis for which the service was performed.
• An added course of treatment other than the normal recovery from surgery.
• Return to the operating room due to complications.
• Immunosuppressive therapy following transplant surgery.

HMSA will review the claim on an individual basis when one of the following modifiers is used:

Claims Filing Information

For surgeons who perform surgical and postoperative services: In processing claims for major surgical procedures, HMSA recognizes only the procedure code that applies to the surgery performed. Please do not bill postoperative visits separately from the surgical procedure.

Revision History