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Chapter 4.5. Division of Workers' Compensation
SUBCHAPTER 1. ADMINISTRATIVE DIRECTOR -ADMINISTRATIVE RULES
Article 5.3. Official Medical Fee Schedule
§9789.16.1. Surgery - Global Fee.
(a) Global Surgical Package.
A global surgical package refers to a payment policy of bundling payment for the various services associated with a surgical procedure into a single payment covering the operation and these other services.
(1) Definition of a Global Surgical Package. The National Physician Fee Schedule Relative Value File, (PPRRVU), Global Days column (labeled “Glob Days”), provides the postoperative periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with entries of 000, 010, 090. For workers' compensation, the global period will not apply to codes with “YYY”.
(A) Codes with “000” in the Global Days column are minor procedures or endoscopies with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure are generally not payable.
(B) Codes with “010” in the Global Days column are minor procedures or endoscopies with preoperative relative values on the day of the procedure and postoperative relative values during a 10 day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during the 10-day postoperative period generally not payable.
(C) Codes with “090” in column U are major surgeries with a 1-day preoperative period and 90-day postoperative period included in the fee schedule amount.
(D) Codes with “ZZZ” are surgical codes related to another service and are always included in the global period of the other service. They are add-on codes that are always billed with another service. There is no postoperative work included in the fee schedule payment for the “ZZZ” codes. Payment is made for both the primary and the add-on codes, and the global period assigned is applied to the primary code.
(2) Components of a Global Surgical Package. A global surgical package is applied to all procedures with the appropriate entry in the Global Days column of the National Physician Fee Schedule Relative Value File. The services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, physicians' offices. Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon. However, critical care services (99291 and 99292) are payable separately in some situations.
The global fee includes payment for the following services related to the surgery when furnished by the physician who performs the surgery:
(A) Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;
(B) Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a surgical procedure;
(C) Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room (OR). For the purposes of this section, an operating room is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient's condition was so critical there would be insufficient time for transportation to an OR);
(D) Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery;
(E) Postsurgical Pain Management - By the surgeon;
(F) Supplies - Except for those identified as exclusions; and
(G) Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
(3) Services Not Included in the Global Surgical Package. The services listed below may be paid for separately:
(A) The initial evaluation of the problem by the surgeon to determine the need for a major surgical procedure. (The initial evaluation is always included in the allowance for a minor surgical procedure and is not separately payable);
(B) Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care; this agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;
(C) Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
(D) Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;
(E) Diagnostic tests and procedures, including diagnostic radiological procedures;
(F) Clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment for complications. (A new postoperative period begins with the subsequent procedure.) This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. Examples of this are procedures to diagnose and treat epilepsy (codes 61533, 61534-61536, 61539, 61541, and 61543) which may be performed in succession within 90 days of each other;
(G) Treatment for postoperative complications which requires a return trip to the operating room (OR);
(H) If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;
(I) Splints and casting supplies are payable separately;
(J) Immunosuppressive therapy for organ transplants; and
(K) Critical care services (codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.
(L) Services that fall within section 9789.16.4 (Primary Treating Physician's Progress Reports, and specified Evaluation and Management visits.)
(4) Minor Surgeries and Endoscopies. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. A postoperative period of 10 days applies to some minor surgeries. The postoperative period for these procedures is indicated in the Global Days column of the National Physician Fee Schedule Relative Value File. If the Global Days column entry is “010”, no separate payment is allowed for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure. If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the 10-day period, the major surgery is payable separately. Services by other physicians are not included in the global fee for a minor procedure except as otherwise excluded. If the Global Days column entry is “000”, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. Separate payment is made in this instance.
(5) Physicians Furnishing Less Than the Full Global Package. There are occasions when more than one physician provides services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the postoperative, postdischarge care is split between two or more physicians where the physicians agree on the transfer of care. When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services, except where permitted. When either modifier “-54” or “-55” is used, a percentage of the fee schedule is applied as appropriate. The percentages for pre-, intra-, and postoperative care of the total RVUs for major surgical procedures and for minor surgeries with a postoperative period of 10 days may be found in the columns Preoperative Percentage (“Pre Op”), Intraoperative Percentage (“Intra Op”), and Postoperative Percentage (“Post Op”), respectively, of the National Physician Fee Schedule Relative Value File. The intra-operative percentage includes postoperative hospital visits. Split global care does apply to procedures with “000” in column U of the National Physician Fee Schedule Relative Value File.
(6) Determining the Duration of a Global Period. To determine the global period for major surgeries, count 1 day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery. To determine the global period for minor procedures, count the day of surgery and the appropriate number of days (either 0 or 10 days) immediately following the date of surgery.
Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.
1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).
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