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Last Modified: 11/2/2018 Location: FL, PR, USVI Business: Part B

Out-of-state surgery with post-op in-state FAQ

Q. For a patient who has had a surgery performed elsewhere (e.g., out of state), can the patient be seen for post-op care by a local physician and can the local physician bill for an E/M visit?
A. As long as the service is medically necessary and the component work has been provided, a separate evaluation and management (E/M) service could be billed without modifier 24, since the physician seeing the patient is not the same one who performed the surgery.
However, there are occasions when more than one physician provides services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish follow-up care. Payment for the postoperative, post-discharge care is split between two or more physicians where the physicians agree on the transfer of care.
When more than one physician furnishes services included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services.
Where physicians agree on the transfer of care during the global period, the following modifiers are used:
Modifier 54 is for surgical care only; or
Modifier 55 is for postoperative management only.
Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.
Source: The Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM) Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, Sections 30.6.6, 40.4 external pdf file;
Medicare Learning Network® (MLN®) Global Surgery Fact Sheet external pdf file
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