Certain Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codedescriptions support reimbursement only once during the Defined Treatment Period. Per CPT, these codes include treatment at one or more sessions that may occur at different patient encounters. These codes should only be reported once during the Defined Treatment Periodunless reported with an appropriate modifier. For the purposesof this policy, the Same Physician or Other Health Care Professional includes physicians and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification number.
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Q: What happens if the Same Physician or Other Health Care Professional had to discontinue or reduce the first surgery, but was able to complete the surgery the second time within the same Defined Treatment Period?
A: If the first surgical procedure was reported with a modifier 52 or 53, upon submission of a second unmodified global code within the sameDefined Treatment Period, the partial reimbursement will be adjusted and the global code will be reimbursed.
Q: What happens if the Same Physician or Other Health Care Professional performs the surgery on one eye then performs the surgery on the other eye two weeks later (within the same Defined Treatment Period)?
A: In this case, it is critical that the anatomic modifiers (LT and/or RT) be used appropriately to indicate the eye upon which the surgery was performed with each submission. The subsequent procedure will be considered for reimbursement when appropriate modifiers are reported.
Q: What happens if a different surgeon performs subsequent surgeries in the same Defined Treatment Period?A:If the Same Specialty Physician or Other Qualified Health Care Professional is reporting with the same Federal Tax Identification number (TIN), subsequent surgeries will be denied within the same Defined Treatment Period. If the physician or other health care professional is a different specialty and/or different TIN, subsequent surgeries will be considered for reimbursement.
Q: When does the Defined Treatment Periodof a procedure begin and end?
A: The Defined Treatment Period begins the day of the procedure and then 10or 90 days before the procedure and following the procedure, beginning the first day of the procedure. Example: A procedure having a Defined Treatment Periodof 90 days is performed on 10/1. Procedures reported on 10/1 and during the 90-day treatment periodbefore and after (7/3 through and including 12/30) are included in the treatment period.