Documentation and Modifiers Key When Billing Transfer of Care
Published on Sat Jan 01, 2000
Because most surgeries have a built-in global period that includes postoperative procedures in the fee for the original surgery, getting reimbursed for providing such post-op services for a patient whose procedure was performed by another surgeon can be difficult. But complete communication between the surgeons offices is the key to getting paid for providing post-operative care to such patients.
The global period is supposed to apply only to routine follow-up after surgery, though some private payers interpretations may be considerably broader. Routine follow-up typically means managing the patients recovery from surgeryfor example, making sure the wound heals without infectionnot for treating any other condition the patient has or may develop.
When one surgeon takes over routine management of the patient after an operation by another, both surgeons are supposed to share the reimbursement for the procedure. To inform the payer about the arrangement, the surgeon who performed the procedure bills it with modifier -54 (surgical care only), while the surgeon providing postoperative care bills the same procedure code with modifier -55 (postoperative management only) appended. The payer then divides payment between the two surgeons. According to Medicare guidelines, a percentage (usually 85-90 percent) of the procedures fee goes to the surgeon who performed the operation, and 10-15 percent is allotted to the surgeon providing post-op management.
For the reimbursement to be divided correctly, however, the offices of both surgeons must arrange a transfer of care in writing and coordinate billing so that the modifiers are used correctly.
Overcome Global Period Obstacles
Unfortunately, it doesnt always work that way. Problems often arise because the physician managing the post-op care may not be aware the patient is in a global period. And the operating surgeon may not know the patient will not follow up with him or her but rather will visit a surgeon closer to home after being released from the hospital.
For general surgeons, splitting the global fee between intra- and postoperative care occurs when:
the patient requires surgery when he or she is out of town. The operation is performed by a general surgeon in the location being visited, but once the patient is well enough to return home, he or she will see a local general surgeon for routine postoperative care.
the patient lives in a rural area where the service required is unavailable, so he or she travels to a full-service hospital many miles away. Once the surgery is performed, the patient returns home and visits a local surgeon for post-op treatment.
Although these two scenarios have much in common, there is one important difference between them. In the second scenario, the surgery likely has been organized ahead of time, giving staff in both offices the [...]
