Medical surgical nursing care manual

Benefits are not available for report preparation, telephone consultation, case presentations, or staff consultation. Psychotherapy services provided for the following specific primary diagnoses are not benefits of Health First Colorado. Unusual circumstances or exceptions to allow benefits for these services must be fully documented, reviewed, and prior authorized. Regional Accountable Entities RAEs provide all mental health care to members in their geographical area.

Non-network practitioners who render emergency mental health services must bill the RAE for payment. Members who are dually eligible i. Surgical reimbursement includes payment for the operation, local infiltration, digital block or topical anesthesia when used, and normal, uncomplicated follow-up care. Under most circumstances, the immediate preoperative visit necessary to examine the member is included in the surgical procedure whether provided in the hospital or elsewhere.

Procedures intended solely to improve the physical appearance of an individual but which do not restore bodily function or correct deformity are not benefits of Health First Colorado. Therapeutic legally induced abortions are benefits of Health First Colorado when performed to save the life of the mother.

Health First Colorado also reimburses legally induced abortions for pregnancies that are the result of sexual assault rape or incest. Specific instructions for submitting claims for abortions performed for maternal life-endangering circumstances, sexual assault or incest are described in the Sterilizations, Hysterectomies, and Abortions Billing Instructions section. Assistant surgeon services may be reported by adding the appropriate modifier code 80, 81, or 82 to the surgical procedure code.

Information is entered on the procedure file for those procedures for which Medicare allows assistant surgeon benefits. Payment allowed is up to 20 percent of the surgeon's maximum allowable reimbursement for the first procedure and 5 percent of the surgeon's maximum allowable reimbursement for second and subsequent procedures.

If multiple surgery pricing also applies to services reported with modifier 80, 81 or 82, the assistant surgery pricing will be applied after the multiple surgery discount. Surgeries performed by the same rendering provider for the same member on the same date of service must be submitted on a single claim.

Each rendering provider's procedures should be submitted on a separate claim, even if the claims are submitted by the same billing provider. Health First Colorado covers bariatric surgery for eligible members. A hysterectomy is a benefit of Health First Colorado when performed solely for medical reasons. A hysterectomy is not a benefit when:. Refer to the Sterilizations, Hysterectomies, and Abortions Billing Instructions section for billing requirements. Surgical procedures intended to improve the function and appearance of any body area altered by disease, trauma, congenital or developmental anomalies, or previous surgical processes may be benefits of the program if services are prior authorized.

Physician documentation on the PAR form is the basis for determining the benefit for reconstructive surgery. Voluntary sterilization is a benefit when appropriately documented on the Med form. Refer to the Sterilizations, Hysterectomies, and Abortions Billing Instructions section for sterilization billing requirements.

Organ procurement and transplantation are benefits only when prior authorized. Corneal and kidney transplants are benefits and do not require prior authorization. Donor expenses i. Living organ donations for liver transplants require the transplant recipient to have received prior authorization for a living organ transplant procedure.

Reimbursement is only allowed for the approved donor. Expenses for donors who are tested and not approved are not covered. Donor expenses should be billed on the recipient's transplant claim using the recipient's Medicaid identification number. Important: Organ transplants are not a covered benefit for non-citizens. Health First Colorado utilizes the general surgical guidelines, subsection instructions, and procedure code modifiers found in each year's CPT codebook published by the AMA.

The following information is in addition to the CPT guidelines, and should be utilized for billing Health First Colorado and reimbursement purposes. When two or more procedures subject to multiple surgery pricing are reported on a claim, the surgery procedure commanding the greatest allowable payment will be reimbursed at percent of the allowed amount, the surgery procedure with the second greatest allowable payment at 50 percent and subsequent surgery procedures at 25 percent.

Services must be billed on the same claim to receive payment for multiple surgical services rendered on the same date of service, for the same member, by the same rendering provider. If a separate claim is billed for the same rendering provider, the subsequent claim will deny. If multiple surgeons provide services to a member on the same date of service, report each rendering provider's procedures on a separate claim.

Unless otherwise identified in the CPT-4 listings, bilateral procedures requiring a separate incision that are performed at the same operative session, should be identified by the appropriate five-digit code describing the procedure with modifier 50 added to the procedure code.

Use of this modifier should be limited to procedures for which "bilateral" services are appropriate according to the MPFSDB. Bilateral procedures indicated using modifier 50 will be reimbursed at percent of the maximum allowable for the procedure. If multiple surgery pricing also applies to services reported with modifier 50, the multiple surgery discount will be applied after the bilateral pricing.

Each surgeon should report the co-surgery once using the same procedure code. If additional procedure s including add-on procedure s are performed during the same surgical session, separate code s may also be reported with modifier 62 added.

Note: if a co-surgeon acts as an assistant in the performance of additional procedure s during the same surgical session, those services may be reported using separate procedure code s with modifier 80 or modifier 82 added, as appropriate. Procedures appropriate for co-surgeon reimbursement are listed on the Medicare Physician Fee Schedule Database with a co-surgery indicator of 2. Report each rendering provider's procedures on a separate claim, even if the claims are submitted by the same billing provider.

Procedures reported with modifier 62 will be priced at Multiple surgery discounting will be applied to eligible procedures after the A reimbursement reduction is applied to multiple endoscopic procedures within the same family performed by the same physician on the same member on the same day.

When a claim contains multiple endoscopy procedures within the same family, the procedure with the highest allowable payment will be reimbursed at percent of that amount, the procedure with the next highest allowable payment will be reimbursed at 80 percent, and subsequent procedures will be reimbursed at 50 percent.

Reimbursement for endoscopic procedures within the same family is calculated independently of discounts that might apply to other lines on the claim, including other families of endoscopic procedures, or multiple surgeries. Payment for a surgical procedure includes the pre-operative, intra-operative, and post-operative services routinely performed by the surgeon.

The post-operative period for each surgical procedure code is determined by the value given in the MPFSDB, and is either 0, 10, or 90 days. Evaluation and management services rendered by the surgeon during this period that are related to the original surgery are included in the payment for the surgery, and not separately reimbursable.

The two procedures are considered to be related when the first three digits of the diagnoses are the same. Modifiers for reporting separately identifiable services during the postoperative period are described at the end of this manual. When post-operative care is performed by a provider other than the physician who performed the surgical procedure, additional reimbursement is allowed only if the post-operative care is reported by a different billing provider. Additional reimbursement is not allowed for post-operative care reported by the same billing provider as the surgery.

Unlisted surgery codes with dates of service on or after November 1, , will be priced by a clinical reviewer with the Department's fiscal agent. Claims with unlisted codes must include as attachments the operating report from the procedure and the Unlisted Procedure Code Form. All lines on the Unlisted Procedure Code Form must be completed.

The Department will deny claims lacking the required attachments. Claims denied for incomplete information will have to be resubmitted with the correct information for reimbursement. The following procedure codes must be accompanied by the Unlisted Surgical Procedure Code Form and an operating report:. The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS claim form. For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.

Back to Top Anesthesia Services General Benefits Anesthesia benefits are provided for medical, surgical and radiological procedures. The following services are considered incidental to the anesthesia service and no separate benefit is allowed: Total body hypothermia in combination with or in addition to procedure codes described as "open" or "bypass" Endotracheal intubation or extubation Back to Top Anesthesia by Surgeon Local infiltration, digital block, or topical anesthesia administered by the operating surgeon is included in the surgical reimbursement and no additional benefit is available.

Back to Top Obstetrical Anesthesia Epidural anesthesia by a provider other than the delivering practitioner is a covered benefit. Back to Top. Colorado Official State Web Portal. Preoperative evaluation Postoperative visits Anesthesia care during the procedure. Cosmetic surgery solely for improvement of physical appearance Telephone call charges for prescriptions Immunizations for the sole purpose of overseas travel Missed appointments Telephone consultation.

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Cancel Forgot your password? Clinical notes and cautions stress key points or alerts related to various disorders and conditions. An overview of nursing considerations for the hospitalized patient includes concepts relevant to many disorders, such as perioperative care, pain, prolonged bed rest, psychosocial support, and older adult care.

Attractive two-color design highlights key information for fast reference. A durable, water-resistant cover prolongs the life of the book. Transfusion Reactions NEW!