Ophthalmology and Optometry Coding Alert

Question: Our practice has one doctor (Dr. A) who comes to our office from another state once a month. He performs surgery - a glaucoma repair, for example - and another doctor here (Dr. B) sees the patient one week afterward for a follow-up exam and to remove the stitches. This is usually the only post-op care Dr. B provides, and he thinks he should be able to bill for his time. He doesn't want to split the global payment with Dr. A; he thinks Dr. A should get the full reimbursement. Dr. B just wants to be paid for the time in which he saw the patient once and removed the stitches. What can I do?

Mississippi Subscriber

Answer: The only way that Dr. B will see reimbursement for his time with the patient is if you report the main surgery code and append modifier -55 (Postoperative management only).

In your example of glaucoma repair, 66150 (Fistulization of sclera for glaucoma; trephination with iridectomy), Dr. B's postoperative care would earn him 20 percent of the total global reimbursement. (See columns P, Q and R of the Physician Fee Schedule Database for percentages allowed for pre-, intra- and postoperative care.)
Insurers would likely view any work he did for the patient within the 90-day postsurgical period - such as E/M services or suture removal - as bundled into 66150 and deny any separate claim.

Beware: For a claim with modifier -55 to be successful, Dr. A must have reported 66150 with modifiers -54 (Surgical care only) and -56 (Preoperative management only) appended. This would entitle him to 80 percent of the global amount (adding the pre- and intraoperative care amounts).

In this case, it would be incorrect for Dr. A to report the global code with no modifiers and receive reimbursement for work he did not perform. Because Dr. A does not see the patients for any postoperative visits, he should only be reporting the pre- and intraoperative portions of the procedure.

Giving Dr. A the full global amount may appear to insurers as if you're paying him extra for work he did not perform, which might provoke an audit. Using modifiers -54, -55 and -56 to split the global amount between the two doctors is both the most accurate and the most ethical way to report their work.