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.
CPT Professional Edition: Current Procedural Terminology (Current Procedural Terminology, Professional Ed. (Spiral): American Medical Association (AMA); 2016 Edition
Understanding Modifiers (Optum Learning Series) (Optum Learning: Coding & Reimbursement Educational); 2015 Edition.
Refer to Medicare's Physician Fee Schedule Search page to perform a search using the Pricing Information search option. Scroll-right to the column that corresponds to Intra Op:
Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUD (October - December)
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
Policy: 03.00.28l:Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period