Last Modified: 5/23/2024
Location: FL, PR, USVI
Business: Part B
Physicians who perform the surgery and furnish all the usual pre- and post-operative work should bill for global surgical care by using the proper CPT surgical code(s). In this situation physicians should not bill separately for visits or other services that are included in the global package. No modifier is necessary.
When different physicians in a group practice participate in the care of the patient and all the physicians reassign benefits to the group, the group bills for the entire global package. The physician who performs the surgery is shown as the performing physician. No modifier is necessary.
Occasionally a physician must transfer the care of the patient during the global care period. In these instances, the use of a modifier will be necessary to distinguish who is providing care for the patient. First Coast expects these instances to be rare.
• The operating surgeon is unavailable after surgery and the patient's postoperative care has to be managed by another physician.
• The patient is unable to travel the distance to the surgeon's office for postoperative care visits.
• The care is provided in a health professional shortage area (HPSA) and the patient is unable to travel to the surgeon's office.
• The surgeon practices in a site remote from where the patient recuperates, e.g., the surgery is performed in a remote area and the surgeon does not return to the area frequently enough to provide the preoperative or postoperative care.
• The patient voluntarily wishes to be followed postoperatively by another physician.
• The surgery is performed by an itinerant surgeon in a remote area of the country.
Transfer of postoperative care is not covered if:
• The operating surgeon is available, and he/she can manage other patients postoperatively, unless the patient voluntarily wishes to be followed postoperatively by another provider.
• The surgeon does follow the patient postoperatively but splits the fee with another provider.
• Two or more physicians co-manage patients indiscriminately as a matter of policy and not on a case-by-case basis.
• A physician demands to manage the postoperative care and indicates that he/she will withhold making referrals to surgeons who would not agree to split global surgery payments.
• A surgeon opts to transfer postoperative care.
• The transfer is not made in writing.
• The transfer of care is used as an incentive for obtaining referrals from providers to receive postoperative care reimbursement.
• The patient has not consented to transfer of care even after being apprised of the medical and/or logistic advisability or the risks and benefits of transfer care.
Specific billing guidelines must be followed when the surgical procedure and post-operative care is split between different physicians. Modifiers 54 and 55 are used to indicate two different physicians are rendering the surgical care and post-operative management services. Where physicians agree on transfer of care during a 10-day or 90-day global period, the following modifiers are used:
• 54 for surgical care only, or
• 55 for postoperative management only
Physician rendering:
• One-day preoperative care
• Intraoperative services
• Any in-hospital visits
Bill services with:
• Date of the surgery
• Procedure code for the surgery
• 54 modifier to indicate that the bill is reflective only of the surgical care
• If the physician who performed the surgery relinquishes care any time after the surgery, the date of the transfer of care must be indicated in item 19 or the equivalent for electronic submission.
Bill services with:
• Date of the surgery
• Procedure code for the surgery
• 55 modifier
In the case where the surgeon also cares for the patient for some period following discharge, the surgeon should bill the surgery with a 55 modifier and indicate the portion of the post-operative care provided in addition to the surgery with a 54 modifier (to indicate the intra-operative service).
In those cases where the postoperative care is "split" between physicians, the billing for the postoperative care should be reported as follows:
• Report the date of service using the date of the surgical procedure.
• Report the procedure code for the surgical procedure, followed by modifier 55.
• Report the date the post-operative care began and ended along with the number of post-operative care days in the narrative field on electronic claims, or item 19 on the CMS 1500 claim form or the electronic equivalent.
When there is a transfer of postoperative care, Medicare regulations require a written transfer of care agreement between the operating surgeon and the physician assuming care. Both the surgeon and the physician(s) providing the post-operative care must keep a copy of the written transfer agreement in the beneficiary's medical records.
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. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he/she assumes care of the patient using the surgery date as the billed date of service.
Both bills for surgical care only and postoperative care only, must contain:
• Same date of service
• Same surgical procedure code
• Appropriate modifier
Example
Physician A performs a hysterectomy (58150) in the hospital on 04/15/2021. The procedure has a 90-day global period.
The patient was in the hospital for 8 days until 04/23/2021 during which time Physician A administered post-operative care.
On 04/24/2021, Physician B took over the post-operative care, which was administered in the office.
Date of service |
CPT code and modifier |
Place of service |
Quantity |
Item 19 or documentation field |
04/15/2024 (date of surgery) |
58150-54 |
21 |
1 |
Blank |
04/15/2024 (date of surgery) |
58150-55 |
21 |
1 |
Post-operative care performed 04/16/21 to 04/23/21 – 8 days |
Date of service |
CPT code and modifier |
Place of service |
Quantity |
Item 19 or documentation field |
04/15/2024 (date of surgery) |
58150-55 |
11 |
1 |
Post-operative care assumed 04/24/21 to 07/14/21 – 82 days |
We edit claims to ensure split post-operative care claims contain the following:
• Date of service = date of surgery
• Item 19/electronic equivalent = the date post-operative care began and ended along with the number of post-operative care days provided
Claims that do not contain the above information will reject.
Fee schedule amount for the code x (pre-op % + intra-op %)
Example
Provider performed pre- and intra-operative care only for procedure code 66984:
• Provider bills 66984 with modifier 54
• Medicare physician fee schedule (MPFS) shows the pre-operative portion of the payment is 10% and the intra-operative portion of the payment is 70% of the fee schedule amount for this code, for a total of 80%.
• If the allowed amount for the service is $556.96:
• $556.96 x 80% (0.80) = $445.57 (rounded to the nearest cent)
• $445.57 is the allowed amount for this service
Fee schedule amount for the code x post-op %
Examples
Provider performed post-op care only for procedure code 66984:
• Provider bills 66984 with modifier 55
• Bill the date of the surgery (not the day the provider assumed post-operative care)
• Include the dates of post-care in the narrative section of the claim
• MPFS shows the post-operative portion of the payment is 20% of the fee schedule amount for this code
• If the allowed amount for the service is $556.96:
• $556.96 x 20% (0.20) = $111.39
• $111.39 is the allowed amount for this service
If the provider performed 8 days of the post-operative care for 66984:
• Provider bills 66984 with modifier 55
• Bill the date of surgery (not the day the provider assumed the post-operative care)
• Include the dates of the post-care in the narrative section of the claim
• MPFS shows the post-operative portion of the payment is 20% of the fee schedule amount for the cost
• If the allowed amount for the service is $556.96:
• 556.96 x 20% = $111.39 (rounded to the nearest cent)
• $111.39 x 8.9 % (0.089) = $9.91
• $9.91 is the allowed amount for this service
The surgeon should write usual operative note and the physician providing postoperative care should document appropriate follow-up care notes.
Transfer of care must be in writing and dated. The record must indicate the exact date in which post-operative care is assumed by the co-managing physician.
Medical record must indicate that the patient was appropriately informed of the medical and/or logistic advisability of transfer of care along with any risks or benefits of this arrangement, and that the patient gave consent to this arrangement prior to its inception.
All documentation including the documentation that the patient was properly informed must be available to Medicare upon request.
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