CAM 564

Surgical Guidelines (Secondary, Multiple Procedures, Co-Surgeons, Assistant Surgeons, Stand- By Physicians, Microsurgery/Microdissection)

Category:Surgery   Last Reviewed:September 2018
Department(s):Medical Affairs   Next Review:September 2019
Original Date:April 1987    

Description:
Surgical Service consists of operative or cutting procedures or the treatment of fractures or dislocations; such service includes the usual, necessary and related preoperative and postoperative care, when performed by a physician, subject to the following policy guidelines.

Policy Statement:
If two or more operations or procedures are performed at the same time, through the same surgical opening or by the same surgical approach, the total amount covered for such operations or procedures will be the Allowable Charge for the major procedure only.

If two or more operations or procedures are performed at the same time, through different surgical openings or by different surgical approaches, the total amount covered will be the Allowable Charge for the operation or procedure bearing the highest allowance, plus one-half (1/2) of the Allowable Charge for all other operations performed.

If an operation consists of the excision of multiple benign skin lesions, the total amount covered will be paid according to the Allowable Charge for the procedure bearing the highest allowance, 50 percent for the procedure bearing the second (2nd) and third (3rd) highest allowance, 25 percent for the procedures bearing the fourth (4th) through the eighth (8th) highest allowance and 10 percent for all other procedures.

If an operation or procedure is performed in two or more steps or stages, coverage for the entire  operation or procedure will be limited to the Allowable Charge set forth for such operation or procedure.

Microdissection or Microsurgery:
A surgical operating microscope is utilized to obtain good visualization of fine structures in the operating field.  It is appropriate, under specific circumstances, to allow reimbursement for the use of this equipment.  Such surgeries include, but are not limited to:

  • Microdissection and/or microsurgery when it involves very small blood vessels (e.g., hand surgery).
  • Neurosurgical techniques involving microdissection of nerves and/or micro anastomosis of transected peripheral nerves (e.g., reattachment of digits).
  • Neurosurgical procedures involving microdissection and/or microsurgery for intracranial or spinal procedures.

Reimbursement for claims filed outside of the above criteria should be reviewed, with the operative note, by the appropriate post pay nurse reviewer.  All questionable cases should be referred by the post pay nurse to the medical director for review.

Co-surgeon:  Two or more surgeons, usually from different specialties, where the participation of both surgeons is necessary in performing a specific operative procedure.  Co-surgeons typically operate on separate body systems.  Co-surgery is always performed during the same operative session.  The Allowable Charge will be covered for the services of only one surgeon or will be prorated between them by the Plan when so requested by the Surgeon in charge of the case.

Assistant Surgeon:  Many contracts will reimburse for these services only when it is a physician who actively assists the operating surgeon in the performance of a surgical procedure.  In this scenario, one physician is acting as the surgeon and the other is acting as an assistant.  Benefits will be provided for an assistant surgeon under the following conditions:

  • There is sufficient complexity to the procedure or the patient’s condition warrants an assistant.
  • An intern, resident or house physician is not available to assist.
  • Non-physicians (e.g., physician assistants, first assistants, certified surgical assistants and nurse practitioners) are considered ancillary support for the surgeon and, therefore, cannot be considered as an assistant at surgery, UNLESS the language of the specific contract specifies differently.

Please review specific contract verbiage for exclusions and/or limitations related to the reimbursement for a physician’s assistant as an assistant at surgery. 

There are surgical procedures that NEVER require an assistant at surgery and will be denied as "Not Medically Necessary."

Procedures that SOMETIMES warrant an assistant at surgery will defer for medical necessity and must be reviewed by the medical staff for disposition.

Reimbursement, for most contracts, will be made at 16 percent of the pricing allowance for the surgical procedure, not to exceed the physician’s actual charge.  Please refer to specific contract for the Assistant at Surgery provisions.

Standby Physicians:  A physician who is asked to "stand by" during certain medical/surgical procedures or situations where the physician is needed to examine, diagnose or treat a patient should a complication arise (e.g., cardiac surgeon or anesthesiologist during cardiac catheterization or PTCA, physician attendance required for ambulance transfer).

Physicians’ services mean professional services performed. The mere availability of a physician to examine, diagnose or treat does not meet the requirements as stated above.

**Please Note**:   
**The allowance for disposable items, needles, dressings, local anesthetics (i.e., lidocaine, marcaine, procaine and xylocaine, etc.) are included in the allowance of the surgical tray (A4550) and should not be billed separately.

** Low-cost medications are included in the allowance of the surgical procedures and, therefore, are not reimbursed as a separate entity.  If a procedure code is an injection (i.e., codes 20550-20610, 64450) the surgical procedure includes the cost of the injection, administration and medication.  A separate charge for medication should not be listed, with the exception of morphine or high-cost medications such as hyaluronic acid derivatives.  New pharmaceuticals developed after this policy will be reviewed by the Medical Director and reimbursement/medical policy will be reviewed at that time.

**This policy does not reflect the sole opinion of the Plan or the Plan medical director.  Although the final decision rests with the carrier, this policy was developed in cooperation with advisory groups, which include representatives from the Quality Medical Advisory Panel.**

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

09/04/2018 

Annual review, no change to policy intent. 

09/07/2017 

Annual review, no change to policy intent. 

09/01/2016 

Annual review, no change to policy intent. 

09/01/2015

Annual review, no changes to policy intent. 

09/11/2014

Annual review, no changes made.


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