Ophthalmology Coding Alert

Know Co-management Guidelines to Avoid Fraud


- Published on Mon, May 01, 2000

Ophthalmologists need to know the key factors in deciding when it is appropriate to co-manage a patient in order to avoid fraud. Its a common scenario: A patient goes to an optometrist for routine care, the optometrist sends the patient to an ophthalmologist for cataract treatment, then the ophthalmologist sends the patient back to the optometrist for postoperative care. This is an example of co-management, which requires the modifiers -54 (surgical care only) and -55 (postoperative management only). But its not as simple as it sounds. The Office of the Inspector General (OIG) of the Department of Health and Human Services reviews these cases to make sure that the surgeon is not giving the postoperative services to the optometrist in exchange for referrals for surgery.

Follow Societies Guidelines

The key point to remember is that the patients interest, and not the economic interest of the physicians, must come first, according to a joint position paper released in February 2000 by the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS).

When modifiers -54 and -55 are used, it means that 80 percent of the fee goes to the surgeon and 20 percent goes to the postoperative physicianproviding that the optometrist provides postoperative care for the full 90 days in the case of a cataract operation. Ophthalmologists have been concerned about potentially abusive referral arrangements with optometrists who wish to receive the postoperative portion of the Medicare global fee for eye surgery, the Nov. 19, 1999 Federal Register notes in commentary to a rule regarding safe harbors. The ophthalmologists allege that many optometrists refer patients to ophthalmologists on the condition that patients be referred back to the optometrists for post-
surgical care, often without regard to clinical appropriateness, the commentary says. One commentary described a situation where an optometrist/ophthalmologist network referred patients for cataract surgery only to ophthalmologists who would agree to split the global surgical fee by referring the patient back to the optometrist for postoperative care. The optometrist referred their patients to an ophthalmological surgery center 200 miles away when there were at least 50 available ophthalmologists from 7 to 35 miles away.

In response, Medicare modified the scope of its safe- harbor rule, to preclude protection for arrangements between parties that share or split a global or bundled payment from a federal healthcare program for the referred patient.

While co-management is interpreted by different carriers with variations of restrictions, the American Medical Association (AMA) and the American College of Surgeons has issued guidelines stating that the operating surgeon has the responsibility for the postoperative care. Co-management is not approved by these societies if economic considerations drive the decision to transfer the [...]

Ophthalmology Coding Alert
Issue - May, 2000
Already a subscriber? LOGIN to read the article.