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How to bill when co managing?

Marina Posted Thu 20th of February, 2020 12:48:56 PM
I am billing codes 66174, 66984, 0191t all together. Do I need to add modifier 54 to all 3 codes when co managing with another Dr or do I just add modifier 54 to code 66984?
SuperCoder Answered Mon 24th of February, 2020 06:03:34 AM

Thank you for the Question!

 

Modifier 54 is applicable with both the CPT codes. Hence you can append modifier 54 with both the CPT codes 66984 & 66174  but not applicable with 0191T. Medicare expects two co-managing physicians to use these modifiers to break up the global surgery fee on the fee schedule when each physician handles different aspects of the global package. Modifier -54 identifies the work done preoperatively (10 percent of the global package fee) and the intraoperative work, the surgery itself (70 percent of the global package fee). 

 

If the surgeon performs the preoperative and intraoperative portion of the procedure, he or she append modifier -54 to the surgery code. The service will be approved at 80 percent of the Medicare allowable for the surgery. If the other physician provided all 90 days of the postoperative care, he or she would bill the surgery code with modifier -55 appended and would be paid 20 percent of the Medicare allowable for the surgery.

 

Co-Management Recommendations

 

Before using modifiers -54 or -55 ophthalmologists and optometrists should consider the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery's recommended guidelines:

 

1. There must be a justifiable reason for co-management, such as itinerant surgery in a rural area or the patient's inability to travel to the surgeon.

 

2. No transfer for postoperative care should take place unless it is in the patient's best interest.

 

3. Co-management must not be done routinely on all patients, but only on selected patients.

 

4. The surgeon must remain accessible to the patient during the postoperative period at no additional cost. If the patient leaves the optometrist and returns to the surgeon for postoperative care, the two providers must file corrected claims.

 

5. The ophthalmologist must tell the patient what the financial implications are of co-management with respect to the optometrist's reimbursement and the patient's payment obligations. The AAO also stipulates that the patient should agree to the transfer of care before the transfer is made.

 

https://www.supercoder.com/coding-newsletters/my-ophthalmology-coding-alert/coordinate-co-management-care-with-modifiers-54-and-55-article

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf

Hope this Helps!

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