In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
As used in this policy, postoperative period refers to the period of time following a surgical or other invasive procedure during which reimbursement for certain procedures or services is included in the global surgical reimbursement to the provider or provider group.
As defined by the Centers for Medicare & Medicaid Services (CMS) and applied by the Company, reimbursement for a surgical procedure includes a standard global surgical package, which includes preoperative, intraoperative, and postoperative services.
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period
Policy: 03.00.11b:Modifier 77: Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional
Policy: 03.00.12f:Modifier 78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period