Plaw4444
Contributor
Our medical group has a contractual agreement with an outside surgical group whose place of service is "26" (this surgical group is not part of our group). This agreement permits us to provide "Co-management" services for patients' continuation of care after their initial surgery.
Co-management care is performed by our providers at our medical office location/place of service is "11". Our correlating medical claims have always reflected place of service " 11 ", and the surgical cpt code "i.e. 66984" with modifiers "55", and the eye location modifier "RT" (or "LT"). Claims of this nature were always paid by Medicare or various Commercial Plans.
Our pursuit of this denied payment resulted in the plan's Network Provider "Educator" communicate to us the following, "...Modifiers 54 or 55 for exact global day period is accurately reflected, however the surgery itself would need to be coded in the appropriate place of service where the surgery was performed...Although we are coding correctly to indicate co-management by way of the "55" modifier, our group is inaccurately reporting the place of service".
Don't we have to use the same surgical cpt code that was originally performed?
Don't we have to indicate our co-management place of service as "11"?
How is this to be coded any other way than how we have always been coding heretofore? Patients are seen for post-op care at our medical non-facility offices, therefore, coding POS 21 Inpatient Hospital OR 22 Outpatient Hospital 23 OR Emergency Room Hospital would be fraudulent.
Conclusion: Billing with Surgical CPT Code, modifier -55, POS 11. Correct or Incorrect?
Co-management care is performed by our providers at our medical office location/place of service is "11". Our correlating medical claims have always reflected place of service " 11 ", and the surgical cpt code "i.e. 66984" with modifiers "55", and the eye location modifier "RT" (or "LT"). Claims of this nature were always paid by Medicare or various Commercial Plans.
Our pursuit of this denied payment resulted in the plan's Network Provider "Educator" communicate to us the following, "...Modifiers 54 or 55 for exact global day period is accurately reflected, however the surgery itself would need to be coded in the appropriate place of service where the surgery was performed...Although we are coding correctly to indicate co-management by way of the "55" modifier, our group is inaccurately reporting the place of service".
Don't we have to use the same surgical cpt code that was originally performed?
Don't we have to indicate our co-management place of service as "11"?
How is this to be coded any other way than how we have always been coding heretofore? Patients are seen for post-op care at our medical non-facility offices, therefore, coding POS 21 Inpatient Hospital OR 22 Outpatient Hospital 23 OR Emergency Room Hospital would be fraudulent.
Conclusion: Billing with Surgical CPT Code, modifier -55, POS 11. Correct or Incorrect?