This policy addresses the indications and limitations for outpatient co-management of inpatient and outpatient surgical procedures assigned a 10-day or 90-day global care period. It also provides appropriate documentation guidelines.

The operating surgeon shall be responsible to perform pre-operative surgical evaluations and post-surgical management, even if another health care provider examines or provides care for the patient.

In the unusual event that the operating surgeon is unable to personally provide post-surgical management, the operating surgeon may, by pre-arrangement and with the patient’s prior consent, delegate the post surgical responsibility to another physician.

The physician receiving the patient must be licensed to manage all aspects of the postoperative care, including the ability to diagnose potential complications that would require another operation.

In all instances the transfer of global surgery must be medically necessary and appropriate. The transfer of surgical care is allowed only to protect the legitimate interest of the member as outlined in the indications.

Co-management with another physician is medically necessary in the following special circumstances:

1. The patient is unable to travel the distance to the surgeon’s office for postoperative care visits, including provisions for remote care, HPSA care, and operations required during patient vacation, travel or temporary living arrangements.
   
   
2. The patient develops second illness that prevents travel to the operating surgeon.
   
   
3. The patient provides a written valid request to be followed postoperatively by another physician.
   
   
4. The surgeon develops an injury, illness, or circumstance that prohibits the performance of the postoperative care.

A surgeon may co-manage with a licensed non-physician practitioner when all of the following circumstances apply:

1. The surgeon and the non-physician practitioner work in the same professional practice.
   
   
2. The surgeon or surgeon's group supervises the non-physician practitioner.
   
   
3. The non-physician practitioner is a physician’s assistant, midwife or advanced practice nurse employed by the surgeon or the surgeon's group.

NOTE:

The services of the licensed NPP are included in the global fee for the surgical procedure.

Co-management with a non-physician practitioner is medically necessary in the following limited circumstances:

1. Patient is unable to travel the distance to the surgeon’s office for postoperative care visits, including provisions for remote care, HPSA care, and operations required during patient vacation, travel or temporary living arrangements.
   
   
2. The patient develops a second illness that prevents travel to the operating surgeon.
   
   
3. The patient provides a written valid request to be followed postoperatively by another physician.
   
   
4. The surgeon develops an injury, illness, or circumstance that prohibits the performance of the postoperative care.
   

The operating surgeon may delegate post-surgical management to a non-physician when all of the following conditions are met:

1. The non-physician health care provider is licensed and operating within their lawful scope of practice.
   
   
2. The mutually agreed upon time or circumstance of patient referral is clinically appropriate.
   
   
3. The operating surgeon and/or the non-physician practitioner do NOT receive payment from one another for the referral.
   
   
4. The non-physician practitioner maintains close communication and is able to quickly refer back to the primary surgeon or his designee should complications surface that require physician attention.
   

Co-management Consent Requirements

A valid co-management consent must include the following components:

1. Exact date the post-operative care is assumed by the co-managing physician
   
   
2. Indication the patient or legal patient designee was informed of the medical and/or logistic
   advisability of transfer of care along with risks or benefits of this arrangement
   
   
3. Indication the patient or legal patient designee gave consent prior to inception
   
   
4. Patient or legal patient designee’s signature, and date
   
   
5. Witness signature and date

Reasons for Noncoverage

The transfer of postoperative care services is not medically necessary in the following circumstances:

1. The operating surgeon is available and actively managing other patients, unless the patient requests in writing to be followed postoperatively by another provider.
   
   
2. The surgeon follows the patient postoperatively but splits the fee with another provider.
   
   
3. Indiscriminant co-management as a matter of policy and not on a case-by-case basis
   
   
4. Threats of withholding cases to surgeons who do not agree to split global surgery payments
   
   
5. Transfer of postoperative management for financial benefits and not for medical indications
   
   
6. Transfers without patient or patient's designee's consent or valid co-management consent not on file

Claims for co-management will be considered not medically necessary in the following circumstances:

1. Circumstances listed in the “Limitations” subsection of this policy apply
   
   
2. The medical record documentation does not support the “Documentation Requirements” section of this policy.

NOTE:

Submission for the transfer of postoperative care services that do NOT meet the conditions outlined in this policy may result in RAC and fraud referrals. 

Services not meeting the criteria listed on this policy will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Documentation Requirements 

1. All documentation must be maintained in the patient’s medical record and available upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).
   
   
3. The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
4. The submitted medical record should support the use of the selected diagnosis code(s).
   
   
5. The submitted CPT/HCPCS code should describe the service performed.
   
   
6. The surgeon should write his/her usual operative note.
   
   
7. The physician providing postoperative care should document appropriate follow-up care notes.
   
   
8. A valid co-management consent, if indicated, must be maintained in the medical record and available upon request.

Provider News

04/2012, Medicare Advantage coverage of outpatient co-management of surgical procedures explained

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.