Surgical procedures not found on the Outpatient Fee Schedule

Surgical procedures not listed on the Outpatient Fee Schedule are individually reviewed for payment consideration when performed in a hospital outpatient setting. IBC may also request medical records to help determine a reimbursement rate or to ensure that the procedure code reported accurately represents the surgery performed. If medical records are requested, IBC will make a determination regarding reimbursement once the documentation is received.

Variations before and after surgery 

Preapproval by IBC is based on the code for the procedure planned, but the code assigned for billing after the procedure may be different. Assuming the codes are reasonably related, this is not a barrier for payment; however, an updated Preapproval/Precertification may be required. 

Cancelled surgeries 

Currently, three types of outpatient cancelled surgery scenarios are eligible for reimbursement. In order for these claims to be processed correctly, certain coding and billing criteria must be met. Claims submitted that do not meet these criteria will be returned to the facility for correction. Please note the criteria for each of the following scenarios when coding and billing your claims 

Scenario 1: Patient receives preoperative services, but surgery is cancelled.

Example: The patient has preadmission testing for intended cataract surgery but subsequently develops a cold and the surgery is cancelled. 

Coding and billing requirements: 

• Report the principal diagnosis code, which is the reason for the surgery. 
• Report the secondary diagnosis with the appropriate diagnosis code(s) indicating cancelled surgery.  
• Report the HCPCS and/or CPT code(s) for the preoperative services, indicating procedures performed and the date(s) of service. 
• Submit the claim through the standard channels — no medical record review is required. 

Reimbursement: The hospital will be reimbursed for preoperative services according to its Agreement. 

Scenario 2: Planned surgery is stopped before the entire procedure is completed. 

Example: The patient has planned a laparoscopic adhesiolysis. Surgery proceeds as far as the insertion of the laparoscope when the patient develops an arrhythmia and the surgery is stopped.

Coding and billing requirements: 

• Report the principal diagnosis code, which is the reason for the surgery. 
• There is no need to use a diagnosis code indicating cancelled surgery. 
• Code the procedure to the extent it was completed. In this example, the diagnostic laparoscopy code would be used to describe the insertion of the scope. 
• Submit the claim through the standard channels — no medical record review is required.

Reimbursement:  The hospital will be reimbursed to the extent that the procedure was performed (e.g., diagnostic laparoscopy) according to its Agreement.

Scenario 3: Patient was admitted to same day surgery/short procedure unit, but surgery was cancelled before it began.

Example: Some services related to the intended procedure have been rendered. For example, the patient is in the operating room. When anesthesia has been induced, the patient’s blood pressure drops and the procedure is cancelled.

Coding and billing requirements: 

• Report the principal diagnosis code, which is the reason for the surgery. 
• Report the secondary diagnosis with the appropriate code indicating cancelled surgery. 
• Report the HCPCS and/or CPT code for the intended procedure with the correct revenue code for outpatient surgery. 
• Submit the claim to your Network Coordinator with medical records for the encounter and the reasons for the cancellation. Claims submitted without this required information will not be considered for payment

Reimbursement:  The hospital/facility may be reimbursed for surgical procedures cancelled for reasons beyond the hospital’s control. The hospital will be reimbursed at the minor surgery rate (surgical category M) for fee schedule claims or according to their Agreement for all other claims. The procedure will not be reimbursed if the cancellation is due to administrative reasons (e.g., equipment failure, staffing problems).