Wiki Modifier 55 vs consult

[cgrif2]

Please help! Pt has commercial insurance and has a sking accident in Colorado. Patient comes back after surgery/vacation to his home and goes to his Dr. This Dr. wants to charge for a consult 99243 because the patient has come to him to check on his fracture. Also the Dr. says he knows the surgeon in Colorado is not going to submit his claim with a modifier 54. I am thinking we should code 99024/55 because it is during the global period. Any input on this would be greatly appreciated. Thanks

 

[mitchellde]

no you cannot charge a consult and you cannot use the 55 modifier on an E&M code these modifiers are for procedures only
You would be surprised though at how many ski resort location docs are very good at using the 54 modifier. You will need a transfer of care from that doc
such as instruction from the doc to the patient to follow with a doc of choice.
You will have to bill this as the surgical procedure with the 55 modifier.

 

[cgrif2]

Modfier 55 vs consult

Thank you so much for your reply. As you can tell, I was very confused. Thanks for clearing it up for me.

 

[bdipuma]

Modifier 54 & 55

I understand the usage of the modifiers 54 & 55. My only question is....what about the fee for the charges? Can the physicians both charge the full amount for this surgery codes or do they have do a % which would total 100%?

 

[aaron.lucas]

They shouldnt charge the full amount, no. That's because these modifiers are used to represent a partial service. Just like you wouldnt bill a global fee on a 26 or TC, you wouldnt with 54, 55, or 56. Different payors have different percentages, I think CMS is 70% for 54, 20% for 55, and 10% for 56, though I could be wrong. And other payors may break it down differently, so you have to know who you're billing. Does that make sense?

 

[mhstrauss]

They shouldnt charge the full amount, no. That's because these modifiers are used to represent a partial service. Just like you wouldnt bill a global fee on a 26 or TC, you wouldnt with 54, 55, or 56. Different payors have different percentages, I think CMS is 70% for 54, 20% for 55, and 10% for 56, though I could be wrong. And other payors may break it down differently, so you have to know who you're billing. Does that make sense?

Agree that the full amount should not be charged. The RVU file has a breakdown of pre-, intra-, and post-op percentage for each surgical code; it does vary by code. Most are close to the numbers Aaron posted above.

Hope this helps!