ED Coding and Reimbursement Alert

Question: We have concerns about how to report a follow up visit to a patient that was seen by one of our ED physicians for fracture care, which we reported with a 54 modifier because he was referred for follow up with an orthopedist for the remainder of the global period. When he showed back up in our ED for part of the follow up care, should we then append a 55 modifier to capture the services provided?

Ohio Subscriber

Answer:  If you did not realistically expect the patient to return for follow up care included in the global period for the procedure initially performed, you were correct to append the 54 modifier to that service. However, it may not make sense to append the 55 for additional care. Assuming the first bill had already been submitted with the 54, it would confuse the payer to receive a second bill from the same group claiming the follow up care that was initially discounted. 

Remember even if a different physician of the same specialty in the same group saw the patient on the unexpected return visit, they will likely be deemed to be the same provider. 

The better choice in this scenario is to report the follow-up visit with the appropriate E/M code, perhaps 99282.  This code choice will not muddy the previous claim and will be a more accurate representation of what may be only one visit in a global package that might normally include multiple follow up examinations.