Medical_Policy

Highmark Commercial Medical Policy - Pennsylvania

Medical Policy:	S-12-013
Topic:	Team Surgery
Section:	Surgery
Effective Date:	May 28, 2018
Issue Date:	May 28, 2018
Last Reviewed:	March 2018

Team surgery is a term which denotes two (2) or more surgeons with different skills, and generally of different specialties, working together to carry-out various procedures of a complicated surgery.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

The individual procedure performed by each doctor on the surgical team must be considered on its own merit on a fee-for-service basis.

Modifier 66, surgical team, must be used to identify team surgery procedures.

To be eligible for reimbursement, the component surgery billed by a member of the surgical team must be a covered service if performed alone.

Surgical operations which could fall under the team surgery concept include, but are not limited to:

Reattachment of limb, digit, etc.
Organ transplants

For example, a kidney transplant procedure could involve the services of a general surgeon, urologist and/or vascular surgeon to remove the diseased kidney, implant the donated kidney, and transplant the ureters.

Team Surgery Payment Indicator

0	Team surgeons are not permitted for this procedure.
1	Team surgeons may be allowed with supporting documentation.
2	Team surgeons permitted.
9	Team surgery concept does not apply.

Procedure Codes

See Table Attachment

Refer to medical policy S-112 Co-Surgery for additional information.

Refer to medical policy S-100 Multiple Surgical Procedures for additional information.

Refer to medical policy S-16 Assistant Surgery Eligibility Criteria for additional information.

Place of Service: Inpatient/Outpatient

Team surgery is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Links

Link to Provider Resource Center for the Medical Policy Update

03/2015, Medical Necessity Criteria and Facility Added to Team Surgery Policy
03/2018, Policy Coverage Update Team Surgery

Link to Table Attachment(s)

Link to References

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.