Otolaryngology Coding Alert

Question: Would you please explain when we should use modifier 55? I am not clear on what "management" means.

If another otolaryngologist, not the physician who performed the surgery, sees a post-op patient and admits him to the hospital during the 42-day global period, is modifier 55 appropriate?

Alabama Subscriber

Answer: You should use modifier 55 (Postoperative management only) when your otolaryngologist assumes all of a patient's postoperative care. For instance, if a patient moves after surgery or returns to his local otolaryngologist for postoperative care after a distant otolaryngologist performs the surgery (such as a neck surgery performed at a distant university medical center), you should claim the postoperative component with modifier 55.

Nitty-gritty: Modifier 55 actually goes on the surgery code. Suppose a Chicago otolaryngologist performs a mastoidectomy (69501, Transmastoid antrotomy [simple mastoidectomy]) on a patient. The patient, who lives two hours away, chooses to see his local otolaryngologist for all postoperative care. The physician who performed the surgery should claim the surgical care only with 69501-54 (Surgical care only). To bill for the mastoidectomy's postoperative component, the local otolaryngologist should report 69501-55. There has to be a formal transfer of care from the surgeon to the otolaryngologist for the post op care and the date of that transfer goes in box 19 on the CMS1500 form. Without showing the formal transfer of care, there will be reimbursement problems when you use modifiers 54 and 55.

The situation you describe does not require a modifier. First, modifier 55 does not apply because the otolaryngologist is performing an episode of care; he is not providing all of the patient's postoperative care.

Second, you do not need a postoperative-period modifier since your physician did not perform the surgery and is not in a global period. Modifiers 24 (Unrelated evaluation and management service by the same physician during a postoperative period), 78 (Return to the operating room for a related procedure during the postoperative period) and 79 (Unrelated procedure or service by the same physician during the postoperative period) apply only to the otolaryngologist who performed the global-period procedure.

Bottom line: Because the otolaryngologist in your example sees a patient and admits him to the hospital and he is not the operating surgeon, you should simply report 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...).