Orthopedic Coding Alert

Orthopedists who perform postoperative care for patients whose surgeries have been performed by other physicians can benefit greatly by billing with modifier -55 rather than E/M codes.

Imagine this: A 35-year-old male goes skiing in Colorado and tears his meniscus (836.0-836.2). An orthopedist performs surgery to excise the torn meniscus, after which the patient returns to his home in Pennsylvania for follow-up care. While many practices bill the follow-up care using standard E/M codes (99211-99215 for established patients), these visits should actually be reported by appending modifier -55 (Postoperative management only) to the code for the surgical repair.

Medicare expects two comanaging physicians to break up the global surgery fee when each physician handles different aspects of the global package. Modifier -54 (Surgical care only) identifies the work the surgeon does, while modifier -55 describes the postoperative work and represents about 20 percent of the global package fee.

For the patient with the torn meniscus, the surgeon who performed the meniscectomy would bill 29881-54, and the orthopedist in Pennsylvania who provides the follow-up care would bill 29881-55.

Modifier -55 is most likely to be used following complex orthopedic surgeries, such as total knee replacements (27447, Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing [total knee arthroplasty]).

For instance, suppose a patient has a total knee replacement in Connecticut, then travels to Florida, where she spends her winters. The Florida orthopedist performs the postoperative care but isn't sure whether she should use modifier -55 or just E/M codes, because she doesn't know whether the orthopedic surgeon already billed the full global fee. This example demonstrates why coordination of care between physicians is so important in these cases. The Florida physician should contact the Connecticut physician to ensure that both are able to bill for their portions of the patient's care by using their respective modifiers.

Modifier -55 can also be useful for meeting insurance plan eligibility. For instance, suppose an orthopedist performs emergency surgery on a patient and is not a participating provider for his HMO plan. After the surgery, the HMO arranges for postoperative follow-up care with an in-network physician. In these situations, the operating physician can use modifier -54 to indicate that he performed surgical care only, and the follow-up physician can append modifier -55 to the procedure code to designate postoperative management.