QUEST Integration – Surgery – Cutting

Original Effective Date:

04/01/1999

Current Effective Date:

01/01/2015

Major Surgery

In line with HMSA’s private businesses, a major surgical procedure is considered to be any procedure performed in an operating room, usually under general anesthesia. Payment for major surgery includes the supplies and equipment used in the surgery as well as care before and after the surgery. The aftercare period for major surgery is 90 days.

Stand-by time is not a benefit. However, up to ½ hour stand-by time is allowed when a pediatrician is in attendance for a C-section delivery and provides immediate care of the newborn.

Claims for hysterectomies or sterilizations and/or any related service or item, including but not limited to surgery assistance, anesthesia, facility services, etc., that is not submitted with a properly signed consent form will be denied. See QUEST Integration – Hysterectomy and QUEST Integration – Sterilizations.

Minor Surgery

Post-operative services rendered within 10 days of a minor surgical procedure are included in the payment for the surgical service. Services rendered within the aftercare period should not be billed separately. (Note: The 10-day aftercare period does not apply to starred procedures as identified in the CPT.) In addition, many procedures can be performed safely and effectively in a physician’s office. A list of minor surgical procedures that should be performed in a physician’s office is included in the Place of Treatment – Office Procedures List. Additional payment for surgical trays will be paid to providers who perform minor surgical procedures in their offices.

Admission Notification

Hospital inpatient admissions must be reported to HMSA by the hospital within 24 hours of the admission, except for routine newborn admissions.

Reconstructive Surgery

HMSA’s Plan for QUEST Integration Members covers reconstructive surgery to restore, reconstruct or correct any bodily function that was lost, impaired or damaged as a result of an illness or injury. Reconstructive surgery for congenital anomalies (e.g., defects present from birth) is payable only when the defect severely impairs or impedes normal, essential bodily function. To prevent misunderstandings, please contact us in advance for a determination of whether the service will be covered.

Please send your written request to:

Pre-Certification Request, 6th Floor

HMSA – Medical Management Department

P.O. Box 2001

Honolulu, HI  96805

Fax: 808-944-5611

Multiple Procedures

When two or more surgery or medical management procedures are performed on a patient by the same physician on the same date of service, benefits will be paid according to the following guidelines.

Same Operative Session – Different Incisions

If different incisions are made during the same operative session, in most cases the full QUEST Integration allowance is paid for the highest-valued procedure and 50 percent of the eligible charge for each subsequent procedure. Certain services like add-on codes are exempt from the multiple surgical procedure payment policy.

Same Operative Session – Same Incision

In most cases, if multiple surgical procedures are performed during the same operative session through the same incision, only the primary procedure will be paid. However, we will review the case if significant secondary conditions, complications and/or unusual circumstances exist that may warrant additional payment. In these cases, please send an operative report for review.

Claims Filing Information

When filing a claim for multiple surgeries pertaining to different incisions during the same operative session, please bill the primary procedure code. For each additional procedure, add modifier code – 51 to the procedure code. Documentation may be requested.

When filing a claim for multiple surgeries pertaining to the same incision during the same operative session, please bill the primary procedure code only. Add modifier code – 22 to the procedure code only if significant and/or unusual complications exist. (In such cases, an operative report must be attached). If a significant secondary procedure is performed, indicate the appropriate CPT code for the secondary procedure and add modifier – 51.

Example

Physician treats patient who has a nasal fracture and a laceration on the back of his hand.

Claim contains:

21325 – Open treatment of nasal fracture, uncomplicated

12002-51 – Simple repair of superficial wounds; extremities, 2.6 to 7.5 cm

HMSA’s QUEST Integration plan will:

Pay the highest-valued procedure its full allowance and the other at 50 percent of its allowance.

Revision History