General Surgery Coding Alert

Identify different services within the global period.

If you skip the modifier when your surgeon splits services with another physician during the global surgical package, you can expect to miss out on pay you deserve — or even expect a claim denial.

Follow our experts’ four tips for shared care to make sure you avoid this complicated billing trap.

Tip 1: Transfer the Care

Here’s a shared care scenario your surgeon might face: Your surgeon sees a patient in the emergency room, diagnoses a ruptured appendix, and performs an emergency appendectomy 44960 (Appendectomy; for ruptured appendix with abscess or generalized peritonitis) for a patient from out of town. The patient receives post-op care within the global period from his own physician after returning home.

In order for both physicians in this scenario to bill for services related to a single surgical procedure, the first thing you have to do is establish transfer of care. 

Do this: When you complete the CMS-1500, make sure that the date of transfer is mentioned in box 19. You can expect denials without documentation of the formal transfer of care. 

Caution: The transfer of care must be for an appropriate reason, such as it is difficult or impossible for the patient to have all of the care in one practice due to the distance involved. Planned sharing of care to get services referred between practices could be subject to prosecution under anti-kickback rules.

Tip 2: Append a Modifier to the Surgical Code

When the physician performs pre-op care and then transfers care to a surgeon, or when the surgeon transfers post-op care to a different physician, you need to communicate the circumstances to the payer. That’s when one of the following three modifiers comes into play:

• 54 — Surgical care only
• 55 — Postoperative management only
• 56 — Preoperative management only.

Do this: Both physicians will bill the surgical code with an appropriate modifier indicating the portion of the global service that each physician performed. In the preceding example, the surgeon would bill 44960-54, while the physician where the patient lives would bill 44960-55. 

Warning: Some payers do not recognize all of these modifiers and will pay parts of the package only to one provider. For example, if you are reporting the service to Medicare and use modifier 54, your surgeon will also receive pay for the preoperative services, because Medicare includes it with the surgery pay. This explains why Medicare doesn’t recognize modifier 56.

Avoid this: Don’t use these modifiers for shared services between two surgeons or other qualified healthcare providers within the same practice.

Tip 3: Check the Payment Impact

According to CMS, “When more than one physician furnishes services that are 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 provides all services.”

Know the exception: CMS states that there are cases when this payment restriction doesn’t apply, for instance, when “the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative care, [those circumstances may] result in payment that is higher than the global allowed amount.”

That means you stand to lose pay if you don’t accurately communicate the shared services — which you should do by correctly using modifiers 54, 55, or 56, for most payers. But using the correct modifiers can be trickier than you think, which is why you need the next tip.

Tip 4: Coordinate Billing

To make sure you get paid for your surgeon’s work, you’ll have to communicate with the other medical practice where the other physician performs part of the surgical package care. 

“The largest hurdle regarding these modifiers is knowing the other office,” stresses Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC, manager of physician compliance auditing at Allegheny Health Network in Pittsburgh, Penn. “If your physician did the surgery but won’t be following the patient, then in order to bill correctly, you should communicate with that office. You would then bill for the pre-op and surgery, the other office would bill for the post op care; everyone would use the same surgery CPT® code instead of E/M service codes for the post-op care.”

Red flag: If you surgeon does the follow-up care and reports the postop care with modifier 55, you need to make sure the physician who performed the surgery reports the surgery with modifier 54. If you don’t, the payer will deny your claim because they may have already reimbursed the surgeon for the full care associated with the code.

“This is where communication between offices is critical. If one of the offices mistakenly forgets to append a modifier, a corrected claim can be sent in to the health plan in order to ensure proper payments to both offices,” says Betty A. Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD, director, ICD-10 Development and Training at the AAPC in Salt Lake City.

Consider locale: If the surgeon and the postoperative care physician perform services in the same Part B contractor jurisdiction, they should both submit their claim to the same MAC. If they’re not in the same Part B MAC jurisdiction, the surgeon should send his claim with modifier 54 to the MAC who covers the area where the surgery is performed. The doctor who performs postoperative care should bill the claim with modifier 55 to the MAC that covers the area where the postsurgical care occurs.