Governing Rules:

• 6.8.1

  HSCs with a designated category code of 1 and 15 include related post-operative services and those with a designated category code of 3, 4, 6 and 14 include both related pre-operative and post-operative services.

  1. a consultation benefit may be claimed up to and including the day of surgery.
  2. pre-operative hospital care may be claimed by the physician who performs the surgery if information is submitted to show that conservative treatment was attempted before surgery was performed.
  3. benefits may be claimed as applicable for complications occurring during or following post-operative time periods.
  4. Deleted
  5. HSC 03.04R may be claimed in the pre-operative time frame when all conditions in the notes have been met.

  The following chart gives the pre-operative and post-operative periods.

  Category	Pre-operative	Post-operative
  1	0 - Days	14 - Days
  3	7 - Days	7 - Days
  4	7 - Days	14 - Days
  6	14 - Days	14 - Days
  14	30 - Days	14 - Days
  15	0 - Days	7 - Days

• 7.1.1 FUNCTIONAL AREA

  Functional area includes the following anatomical areas: Head, face, neck, shoulder, axilla, elbow, wrist, hand, groin, perineum, hip, knee, ankle, foot, and includes coverage of exposed vital structures (bone, tendon, major vessel, nerve). Paired structures would be claimed as two separate areas, e.g., right and left wrist would be claimed as two separate areas.

• 18.1

  The Body Mass Index (BMI) modifier may be claimed for selected procedures, obstetrical services, anesthesia, second qualified surgeon and surgical assistant services provided in any location when the following criteria are met:

  1. An adult patient has a body mass index of 40 or more.
  2. A patient under 18 years of age who is above the 97th percentile for BMI on an approved pediatric growth curve.
  3. The following HSCs are only eligible for the BMI modifier when the service is provided under general, spinal, epidural anesthetic or regional nerve block performed in an operating room, day surgery or surgical suite: 98.11A, 98.11B, 98.11C, 98.11D, 98.11E, 98.11F, 98.22A, 98.22B.