CMS Pub. 100-04, ch. 12, § 40.5

It may not always be possible to identify instances where more than one physician furnishes

postoperative care before the carrier has paid at least one of the physicians. In addition,

situations where a physician renders less than the full global package but does not add the

applicable modifier to the procedure code are not detectable until another physician submits a

claim.

Several other categories of fragmented bills cannot be or are difficult to detect on a prepayment

basis. When a new claim reveals fragmented billing by a single provider after payment for

some services was already made to that physician, carriers must adjust the amount due on the

new claim by the amount previously paid.

When a new claim indicates that an incorrect payment may have been made to another

physician who submitted a previous bill, carriers must determine which bill is correct. (Review

the claims and any submitted records to be sure that the providers correctly used modifiers and

are billing for services that are included in the global fee. If necessary, a carrier representative

must contact one or both physicians to determine which claim is correct.) If the carrier

determines that the first claim is incorrect, they follow the overpayment procedures in the

Medicare Financial Management Manual, Chapter 3, for recovery of the incorrect payment

from the first physician. They pay the second physician according to the services performed.

If the carrier determines that the second claim is incorrect, they deny payment.

The following reflects the remittance advice messages and associated codes that will

appear when rejecting/denying claims under this policy. This CARC/RARC

combination is compliant with CAQH CORE Business Scenario 3.

Group Code: CO

CARC: B20

RARC: N/A

MSN: 7.3

Carriers must include the appropriate language regarding beneficiary liability according to

§40.4.D, above.

Nonparticipating physicians who furnish less than the full global package, but who bill for the

entire global surgery, may be guilty of violating their charge limits. In addition, physicians

who engage in such practices may be guilty of fraud. See the Medicare Financial Management

Manual, Chapter 3, and the Medicare Program Integrity Manual, Chapter 3, for further

information on recovery of overpayments, charge limit monitoring, and fraud.