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post operative billing question #2

Vera Posted Wed 08th of May, 2013 22:34:25 PM

I have the MOST difficulty billing for postoperative care when another doctor did the surgery - What code am I supposed to bill? The main surgery code the other Dr billed? What if they billed 4 or 5 codes? Do i bill one CPT code with a 55, or all CPT codes with 55 ? Then what $ amount do you put there ? I was told the surgical charge amount should be billed, and the insurance company will know, from the 55 modifer, to pay 10% or 20% or whatever is due ? Also,... in box 19, do we put surgical post op dates - from and to dates ?? I am very confused by this whole process and I did post the first post op billing question too ?

so if the patient had a 28730, and the surgeon billed $2500,... I am billing 28730 Lt.55 and the $ amount as $2500 also, with the 55 mod, - which indicates we should only be paid 20% of fee. We do all post op care for our patients we send to out of town surgeons.

I am being told if the surgeon billed, say,... 28296, 28119, 27687, -- I am to bill each code with a 55 mod and the $$ amount that the surgeon billed? Is this correct? Or do we just bill the #1 CPT code?????

Thank you! I am very confused about this.

SuperCoder Answered Wed 08th of May, 2013 23:05:24 PM

Postoperative Management Only: When one physician performs the postoperative management and another physician has performed the surgical procedure, the postoperative component may be identified by adding the modifier 55 to the usual procedure number.
This modifier is used to identify postoperative, out of hospital medical care associated with a given surgical procedure. When billing for postoperative care only, report the original date of surgery as your date of service and the procedure code for the surgical procedure followed by the 55 modifier. In rare situations where the out of hospital postoperative care is split between physicians, each physician must also indicate the period of his/her responsibility for the patient’s postoperative care by reporting the appropriate range of dates. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service.

Orthopedists who perform postoperative care for patients whose surgeries have been performed by other physicians can benefit greatly by billing with modifier -55 rather than E/M codes.

Imagine this: A 35-year-old male goes skiing in Colorado and tears his meniscus (836.0-836.2). An orthopedist performs surgery to excise the torn meniscus, after which the patient returns to his home in Pennsylvania for follow-up care. While many practices bill the follow-up care using standard E/M codes (99211-99215 for established patients), these visits should actually be reported by appending modifier -55 (Postoperative management only) to the code for the surgical repair.

Medicare expects two comanaging physicians to break up the global surgery fee when each physician handles different aspects of the global package. Modifier -54 (Surgical care only) identifies the work the surgeon does, while modifier -55 describes the postoperative work and represents about 20 percent of the global package fee.

For the patient with the torn meniscus, the surgeon who performed the meniscectomy would bill 29881-54, and the orthopedist in Pennsylvania who provides the follow-up care would bill 29881-55.

Modifier -55 is most likely to be used following complex orthopedic surgeries, such as total knee replacements (27447, Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing [total knee arthroplasty]).

For instance, suppose a patient has a total knee replacement in Connecticut, then travels to Florida, where she spends her winters. The Florida orthopedist performs the postoperative care but isn't sure whether she should use modifier -55 or just E/M codes, because she doesn't know whether the orthopedic surgeon already billed the full global fee. This example demonstrates why coordination of care between physicians is so important in these cases. The Florida physician should contact the Connecticut physician to ensure that both are able to bill for their portions of the patient's care by using their respective modifiers.

Modifier -55 can also be useful for meeting insurance plan eligibility. For instance, suppose an orthopedist performs emergency surgery on a patient and is not a participating provider for his HMO plan. After the surgery, the HMO arranges for postoperative follow-up care with an in-network physician. In these situations, the operating physician can use modifier -54 to indicate that he performed surgical care only, and the follow-up physician can append modifier -55 to the procedure code to designate postoperative management.

Vera Posted Mon 13th of May, 2013 17:06:38 PM

Thank you. What amount do you put in the $$ ? The full cost of the surgery and assume the payor knows to reimburse at 20% because of the 55 mod ? What if there is more than one CPT for surgery? Many surgeries have three or four CPT codes ? Does the post operative practice bill just one of those w/ the 55 mod? or all ?

SuperCoder Answered Thu 30th of May, 2013 22:31:46 PM

The two practices must coordinate their efforts for either party to be reimbursed correctly. Please ask the reader if the operating surgeon's practice is submitting their surgical codes with modifier 54 appended; if they are not appending modifier 54, then the practice providing the postop care cannot report the surgical CPT codes with modifier 55 appended. They will have to report the appropriate level E&M service for each postop encounter.

If the operating surgeon's practice is using modifier 54, then the postop care provider should report ALL surgical CPT codes with modifier 55 appended. Report the customary fee for each surgical CPT code and let the payer process the claim before taking any reductions.

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