Update to claims system for global surgical procedures

To align with the Centers for Medicare & Medicaid Services (CMS) guidance, we are updating our claims editing system regarding claim submissions for global surgical procedures. This update will ensure that reimbursements are accurately processed for clearly distinct surgical procedures performed during the postoperative period, excluding re‑operations or complications from treatment. These changes will be effective for dates of service starting on July 1, 2025.

Updated reimbursement eligibility criteria for global surgical procedures

• Claim lines will not be eligible for reimbursement when a 0-day, 10-day, or 90-day global surgical procedure is submitted during the postoperative period of a prior 10-day or 90-day procedure by the same provider for the same member unless it is a distinct procedure.
• The logic reviews the diagnoses reported to the seventh digit.
  If the diagnoses are different, the claim line will be allowed; if the diagnoses are the same, the claim line will not be allowed.
• Modifiers 58, 78, and 79 or site modifiers E1‑E4, F1‑F9, FA, T1‑T9, TA, LM, RI, LC, LD, RC, RT, and LT are appropriate to identify unrelated procedures.

Example

The provider reports procedure code 68761‑E2 and diagnosis code H04.123 with the date of service of January 10, 2025. If the same provider reports procedure code 68760‑E2 and diagnosis code H04.123 with a date of service of January 16, 2025, the claim line for January 16, 2025, will not be allowed since the same site modifier and diagnosis are present as the procedure 10 days prior.

How to Initiate a Claims Payment Dispute

If you believe a claim reimbursement decision should be reviewed, follow the claims payment dispute process outlined in your provider manual, which is available at https://www.anthem.com/provider/individual-commercial/reimbursement.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.