Wiki Modifiers 55 vs 58

[katheyj@southarkortho.com]

We have a patient that had surgery in Texas and is coming home to do his post op. I am a little confused as to which modifier to use 55 or 58. It seems to me that the 55 modifier applies and that the surgeon should file the claim with a 54 modifier. I spoke with the surgeons office and they said they weren't filing with any modifier and that I should file all the follow up with a 58 modifier. She did finally say that if you file your claim and get denied then they would right a letter. Wouldn't it be a cleaner claim if we both used the right codes and modifiers to begin with. Thanks in advance for your help. Kathey

 

[mitchellde]

You cannot use modifier 58 on visit level codes , that modifier is only for procedures. You are correct in that you need to use the 55 modifier and they need to use the 54. Especially if they provided none of the post operative portion. You will need a written transfer of care from that provider and you write short but sweet little note in field 19 indicating a transfer of care from Dr. X. You should do this regardless of whether they agree to use the 54. It will slow up your reimbursement if they don’t.

 

[sxcoder1]

When I worked in ortho, there were many times that we had a patient that had surgery out of state and then came home for post op and the surgeon's office did not code with modifier 54. We always just billed E/M visits, no modifiers.

 

[katheyj@southarkortho.com]

You cannot use modifier 58 on visit level codes , that modifier is only for procedures. You are correct in that you need to use the 55 modifier and they need to use the 54. Especially if they provided none of the post operative portion. You will need a written transfer of care from that provider and you write short but sweet little note in field 19 indicating a transfer of care from Dr. X. You should do this regardless of whether they agree to use the 54. It will slow up your reimbursement if they don’t.

This seems to to be confusing to lots of people. My coder was at a meeting yesterday that told her to bill with a 56 modifier. Now even I know that's a pre op care modifier. Another staff member was told that the surgeon was to bill the CPT code with a 54 and physician doing the follow up should bill the same CPT code with a 55. This makes a little since. My plan was to simply bill E&M, X-ray, etc., so now I'm even more confused.
This wouldn't be that huge of a deal, but I think we are going to start doing followup for a physician that is coming in to cover ER call and will do the surgery and we will do the follow up.

 

[mitchellde]

Just to clarify you also cannot use the 55 modifier with an E&M code you do use the surgical procedure code of the procedure that was performed and append the 55 modifier. This is Instead of an E&M not in addition to.