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CO HCPF Medical-Surgical Billing Manual — Surgical Services

SurgicalServices

activein force · 2026-07-26 – presentas-observed

Surgicalreimbursementincludespaymentfortheoperation,localinfiltration,digitalblockortopicalanesthesiawhenused,andnormal,uncomplicatedfollow-upcare.Undermostcircumstances,theimmediatepreoperativevisitnecessarytoexaminethememberisincludedinthesurgicalprocedurewhetherprovidedinthehospitalorelsewhere.

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Proceduresintendedsolelytoimprovethephysicalappearanceofanindividual,butwhichdonotrestorebodilyfunctionorcorrectdeformityarenotbenefitsofHealthFirstColorado.

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RefertotheReproductiveHealthCareBillingManuallocatedontheBillingManualswebpage.

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Assistantsurgeonservicesmaybereportedbyaddingtheappropriatemodifiercode80,81or82tothesurgicalprocedurecode.TheonlyproceduresallowableforassistantsurgerybenefitsareprocedureslistedontheMedicarePhysicianFeeScheduleDatabase(MPFSDB)withanassistantsurgeryindicatorof2.

Paymentallowedisupto20%ofthesurgeon'smaximumallowablereimbursementforthefirstprocedureand5percentofthesurgeon'smaximumallowablereimbursementforsecondandsubsequentprocedures.Ifmultiplesurgerypricingalsoappliestoservicesreportedwithmodifier80,81or82,theassistantsurgerypricingwillbeappliedafterthemultiplesurgerydiscount.

Servicesrenderedbynon-physicianpractitionersshouldbereportedusingmodifier-ASinadditionto80,81or82.

Surgeriesperformedbythesamerenderingproviderforthesamememberonthesamedateofservicemustbesubmittedonasingleclaim.Eachrenderingprovider'sproceduresshouldbesubmittedonaseparateclaim,eveniftheclaimsaresubmittedbythesamebillingprovider.

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HealthFirstColoradocoversmetabolicandbariatricsurgeryformembersagethirteenyearsandolderwhenmembershaveclinicalobesityandtheserviceismedicallynecessary.Onemetabolicandbariatricsurgeryiscoveredpermemberlifetimeunlessarevisionisappropriatebasedonanidentifiedcomplication.

CoveredprimaryproceduresareindicatedbytheHealthFirstColoradoFeeScheduleandinclude:

Roux-en-YGastricBypass

BiliopancreaticDiversionwithorwithoutDuodenalSwitch

VerticalSleeveGastroplasty

Surgeonsmustbetrainedandcredentialedinmetabolicandbariatricsurgeryproceduresandsurgeriesmayonlybeperformedinahospital.

Criteriaforaprimaryprocedure:BMI

ToqualifyformetabolicandbariatricsurgerymembersmusthaveeitherClassIIIObesity,orClassIIObesityanddocumentationofoneormoreofthefollowingcomorbidities:

Severecardiacdisease

Type2diabetesmellitus

Obstructivesleepapneaoranotherrespiratorydisease

Pseudo-tumorcerebri

Hypertension

Hyperlipidemia

Severejointordiscdiseasethatinterfereswithdailyfunctioning

Intertriginoussoft-tissueinfections,nonalcoholicsteatohepatitis,stressurinaryincontinence,recurrentorpersistentvenousstasisdisease,orsignificantimpairmentinactivitiesofdailyliving

Formemberseighteenyearsofageandolder:

ClassIIObesity=BMIbetween35-39.9

ClassIIIObesity=BMIof40orhigher

Formembersundertheageofeighteen:

ClassIIObesity=BMIgreaterthan120%ofthe95thpercentileforageandsex

ClassIIIObesity=BMIgreaterthan140%ofthe95thpercentileforageandsex

Contraindications

Contraindicationsaredeterminedbasedonnationallyrecognizedstandardsofcare.Contraindicationsmustberuledoutthroughacompletehistoryandphysicalandapsychiatric/psychologicalassessmentthathasbeenconductedwithinthepast12monthspriortotherequestedpriorauthorization.

AdditionalCriteriaMembersmusthaveattemptednonsurgicalweightlossandweightmanagementwithoutsufficientclinicalimprovement.

Membersmustalsoreceivenutritionalcounselingcomprisedofatleastthreevisitswithaproviderwithdocumentedexpertiseinnutrition.Thecounselingmustbeindividualizedforthemember’shealthrelatedsocialneeds.Itcanbeprovidedinpersonorviatelemedicineandmustincludethefollowing:

Identificationofmaladaptiveeatingbehaviorsandpatternsandrecommendationsforaddressingthem

Nutritionalanddietaryeducationforpostoperativesuccess

Educationonmodifyingthemember’smodifiableriskfactorsandcorrectingmicronutrientdeficiencies

Themember’smultidisciplinaryteammustdocumentthatthememberunderstandsandiswillingtocomplywithalong-termpostoperativecareplancreatedbytheteam.

RevisionProcedures

Revisionproceduresarecoveredwhenmedicallynecessarytocorrectcomplicationssuchasslippageofanadjustablegastricband,intestinalobstruction,orstricturefollowingaprimaryprocedure.

Indicationsforsurgicalrevisioninclude:

Weightlossto20%belowtheidealbodyweight

Esophagitis,unresponsivetononsurgicaltreatment

Hemorrhageorhematomacomplicatingaprocedure

Excessivebiliousvomitingfollowinggastrointestinalsurgery

Complicationsoftheintestinalanastomosisandbypass

Stomaldilation,documentedbyendoscopy

Documentedslippageoftheadjustablegastricband

Theprimaryprocedurewassuccessfulininducingweightlosspriortothepouchdilationand

Thememberhasbeencompliantwithaprescribednutritionandexerciseprogramfollowingtheprocedure

Otherandunspecifiedpost-surgicalnonabsorptioncomplications

PriorAuthorizationRequirements

Allmetabolicandbariatricsurgeryproceduresrequirepriorauthorization.Requestsforpriorauthorizationmustincludethefollowing:

Themember’sheight,weight,andBMI

Alistofeachcomorbidcondition,withattentiontoanycontraindicationswhichmightaffectthesurgeryincludingallobjectivemeasurements

Adetailedaccountofthemember’snonsurgicalweightlossandweightmanagementattempt(s)

Adetailedaccountofnutritionalcounseling

Acurrentpsychiatricorpsychologicalassessmentregardingcontraindicationsformetabolicandbariatricsurgery

Adescriptionofthepost-surgicalfollow-upprogram

ProvidersshouldrefertotheCodeofColoradoRegulations,ProgramRules(10CCR2505-108.300.3.C),foradditionalinformationwhenprovidingthisservice.

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Breastreconstructionisabenefitwhen:

MembersmeetrequirementsdescribedintheBreastandCervicalCancerProgram;

MembersmeetrequirementsdescribedintheGender-AffirmingCareBillingManual;

Performedwithinfive(5)yearsofamastectomy;or

ProcedureotherwisemeetsthedefinitionofmedicalnecessityinDept.ruleat10CCR2505-108.076.1.8.

Removalandreplacementofbreastimplantsisconsideredmedicallynecessarywhen:

Theimplantisaffectedbysurgicalcomplicationssuchasrecurrentinfections

Includingwhenimplantswereoriginallyplacedforcosmeticreasons

Theimplantwasoriginallyplacedforreconstructivereasonsand10yearsorlongerhaselapsedsinceoriginalplacement

ProcedureotherwisemeetsthedefinitionofmedicalnecessityinDepartmentruleat10CCR2505-108.076.1.8

Whenreplacementofone(1)breastimplantisconsideredmedicallynecessary,replacementofthecontralateralimplantisalsodeemedmedicallynecessarywhenperformedatthesametime.Allbreastreconstructionandrevisionproceduresrequirepriorauthorization.

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AhysterectomyisabenefitofHealthFirstColoradowhenperformedsolelyformedicalreasons.Ahysterectomyisnotabenefitwhen:

Theprocedureisperformedsolelyforthepurposeofsterilization.

Thereismorethanone(1)purposefortheprocedure,anditwouldnothavebeenperformedexceptforthepurposeofsterilization.

RefertotheSterilizations,HysterectomiesandAbortionsBillingInstructionssectionforbillingrequirements.

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Surgicalproceduresintendedtoimprovethefunctionandappearanceofanybodyareaalteredbydisease,trauma,congenitalordevelopmentalanomalies,orprevioussurgicalprocessesmaybebenefitsoftheprogramifservicesarepriorauthorized.PhysiciandocumentationonthePARformisthebasisfordeterminingthebenefitforreconstructivesurgery.

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VoluntarysterilizationisabenefitwhenappropriatelydocumentedontheConsenttoSterilization-MED178Form.RefertotheSterilizations,HysterectomiesandAbortionsBillingInstructionssectionforsterilizationbillingrequirements.

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Organprocurementandtransplantationarebenefitsonlywhenpriorauthorized.Cornealandkidneytransplantsarebenefitsanddonotrequirepriorauthorization.

Donorexpenses(i.e.,organprocurementassociatedsurgicalandlaboratorycosts)forlivingorgandonationsarecoveredforkidneyandlivertransplants.Livingorgandonationsforlivertransplantsrequirethetransplantrecipienttohavereceivedpriorauthorizationforalivingorgantransplantprocedure.

Reimbursementisonlyallowedfortheapproveddonor.Expensesfordonorswhoaretestedandnotapprovedarenotcovered.

Donorexpensesshouldbebilledontherecipient'stransplantclaimusingtherecipient'sHealthFirstColoradoidentificationnumber.

Important:Organtransplantsarenotacoveredbenefitfornon-citizens.

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HealthFirstColoradoutilizesthegeneralsurgicalguidelines,subsectioninstructions,andprocedurecodemodifiersfoundineachyear'sCPTcodebookpublishedbytheAMA.ThefollowinginformationisinadditiontotheCPTguidelines,andshouldbeutilizedforbillingHealthFirstColoradoandreimbursementpurposes.

TheMedicarePhysicianFeeScheduleDataBase(MPFSDB)designatessomeprocedurecodesassubjecttomultiplesurgerycriteria.Whentwo(2)ormoreproceduressubjecttomultiplesurgerypricingarereportedonaclaim,thesurgeryprocedurecommandingthegreatestallowablepaymentwillbereimbursedat100percentoftheallowedamount,thesurgeryprocedurewiththesecondgreatestallowablepaymentat50percentandsubsequentsurgeryproceduresat25percent.

Servicesmustbebilledonthesameclaimtoreceivepaymentformultiplesurgicalservicesrenderedonthesamedateofservice,forthesamemember,bythesamerenderingprovider.Ifaseparateclaimisbilledforthesamerenderingprovider,thesubsequentclaimwilldeny.Ifmultiplesurgeonsprovideservicestoamemberonthesamedateofservice,reporteachrenderingprovider'sproceduresonaseparateclaim.

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UnlessotherwiseidentifiedintheCPT-4listings,bilateralproceduresrequiringaseparateincisionthatareperformedatthesameoperativesession,shouldbeidentifiedbytheappropriatefive(5)-digitcodedescribingtheprocedurewithmodifier50addedtotheprocedurecode.Useofthismodifiershouldbelimitedtoproceduresforwhich"bilateral"servicesareappropriateaccordingtotheMPFSDB.SeetheUnlistedsectionforinformationonreportingunlistedproceduresperformedbilaterally.

Bilateralproceduresindicatedusingmodifier50willbereimbursedat180percentofthemaximumallowablefortheprocedure.Ifmultiplesurgerypricingalsoappliestoservicesreportedwithmodifier50,themultiplesurgerydiscountwillbeappliedafterthebilateralpricing.

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Whentwo(2)surgeonsworktogetherasprimarysurgeonsperformingdistinctpart(s)ofaprocedure,eachsurgeonshouldreporthis/herdistinctoperativeworkbyaddingmodifier62totheprocedurecodeandanyassociatedadd-oncode(s)forthatprocedureaslongasbothsurgeonscontinuetoworktogetherasprimarysurgeons.Eachsurgeonshouldreporttheco-surgeryonceusingthesameprocedurecode.Ifadditionalprocedure(s)includingadd-onprocedure(s)areperformedduringthesamesurgicalsession,separatecode(s)mayalsobereportedwithmodifier62added.

Note:Ifaco-surgeonactsasanassistantintheperformanceofadditionalprocedure(s)duringthesamesurgicalsession,thoseservicesmaybereportedusingseparateprocedurecode(s)withmodifier80ormodifier82added,asappropriate.

Theonlyproceduresallowableforco-surgeonreimbursementarelistedontheMedicarePhysicianFeeScheduleDatabasewithaco-surgeryindicatorof2.

Reporteachrenderingprovider'sproceduresonaseparateclaim,eveniftheclaimsaresubmittedbythesamebillingprovider.Proceduresreportedwithmodifier62willbepricedat62.5%ofthemaximumallowedamount.Multiplesurgerydiscountingwillbeappliedtoeligibleproceduresafterthe62.5%adjustment.

Forsurgeriesrequiringpriorauthorization,priorauthorizationrequestsmustincludesufficientunitsforeachsurgeon.Forexample,ifaprocedurewillbereportedbytwo(2)surgeons,eachwithone(1)unit,two(2)totalunitsmustbepriorauthorized.One(1)providermayrequestpriorauthorizationonbehalfofbothsurgeons.

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CertainprocedurecodesaredesignatedasendoscopicandplacedintofamiliesaccordingtotheMPFSDB.Areimbursementreductionisappliedtomultipleendoscopicprocedureswithinthesamefamilyperformedbythesamephysicianonthesamememberonthesameday.Whenaclaimcontainsmultipleendoscopyprocedureswithinthesamefamily,theprocedurewiththehighestallowablepaymentwillbereimbursedat100percentofthatamount,theprocedurewiththenexthighestallowablepaymentwillbereimbursedat80percent,andsubsequentprocedureswillbereimbursedat50percent.Reimbursementforendoscopicprocedureswithinthesamefamilyiscalculatedindependentlyofdiscountsthatmightapplytootherlinesontheclaim,includingotherfamiliesofendoscopicprocedures,ormultiplesurgeries.

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Paymentforasurgicalprocedureincludesthepre-operative,intra-operative,andpost-operativeservicesroutinelyperformedbythesurgeon.Thepost-operativeperiodforeachsurgicalprocedurecodeisdeterminedbythevaluegivenintheMPFSDB,andiseither0,10,or90days.Evaluationandmanagementservicesrenderedbythesurgeonduringthisperiodthatarerelatedtorecoveryfromthesurgeryareincludedinthepaymentforthesurgery,andnotseparatelyreimbursable.Thisincludesanyservicesrequiredofthesurgeonduringthepost-operativeperiodbecauseofcomplicationswhichdonotrequireadditionaltripstotheoperatingroom.

Servicesthatareconsideredrelatedtothesurgeryincludebutarenotlimitedto:

Fordatesofservicebefore5/1/2022:Thetwo(2)proceduresareconsideredtoberelatedE/Mserviceswhenthefirstthree(3)digitsofthediagnosesassociatedwiththeE/Marethesamematchthefirstthree(3)digitsofthediagnosesassociatedwiththesurgery.

Fordatesofservice5/1/2022andafter:E/MserviceswhenthediagnosesassociatedwiththeE/Mmatchexactlyanyofthediagnosesassociatedwiththesurgery.

Modifiersforreportingseparatelyidentifiableservicesduringthepostoperativeperiodaredescribedattheendofthismanual.

TheDepartmentwillonlyrecognizemodifiers54and55whenappendedtoCPTcodes66821,66982,66984fromdatesofserviceJune1,2022,forward.Providersmayusemodifier54toreportperformanceofsurgicalcareonlyandmodifier55toreportpostoperativemanagementonly.Theglobalratewillbesplitbetweenthetwo(2)providers.Modifier-specificratescanbefoundontheHealthFirstColoradoFeeSchedule.

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UnlistedsurgeryCPTcodesareusedwhenthereisnoCPTorHCPCScodethataccuratelyidentifiestheservicesperformed.UnlistedsurgerycodeswithdatesofserviceonorafterNovember1,2018,willbemanuallypricedbyaclinicalreviewerwiththeDepartment'sfiscalagent.

CoveredunlistedsurgerycodescanbefoundontheHealthFirstColoradoFeeSchedule.

ClaimswithunlistedcodesmustincludeasattachmentstheoperatingreportfromtheprocedureandtheUnlistedProcedureCodeFormlocatedontheProviderFormswebpageunderClaimFormsandAttachments.AlllinesontheUnlistedProcedureCodeFormmustbecompleted.TheDepartmentwilldenyclaimslackingtherequiredattachments.Claimsdeniedforincompleteinformationwillhavetoberesubmittedwiththecorrectinformationforreimbursement.

Whenunlistedcodesareusedtoreportbilateralsurgery,theUnlistedProcedureCodeFormshouldlistthetotaltimeforbothsidesoftheprocedure.Thestandardbilateralmodifier(modifier50)shouldnotbeused.

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RefertotheVisionCareandEyewearManuallocatedontheBillingManualswebpage.

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Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: cdfba1a95280fa155556727858059ab30b7cce4c272df3d5b31c4d16f5a8a787

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