Wiki Out of State Surgery with Local Follow Up

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grandcanyongirl22@gmail.com

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I have a claim where the patient had surgery out of state and is now seeing our local ortho doctors for a follow up visit for both conditions. Patient had a hip hemiarthroplasty due to a fracture and also has a distal radius fracture. MD is billing 99024 and 99213-24. I think I should bill 99213 because of different tax-id's. But I am wondering about 99024 because it is the same insurance company that paid for the surgery and now the follow up. I have access to outpatient visit notes from the out of state doctor but no billing information. Has anyone encountered this situation?
 
How long did the original surgeon provide post-op care before the patient returned home and your provider assumed the routine post-op care? Depending on how long the surgeon provided post-op care, you may be able to split the billing with the surgeon. The surgeon could bill the pre-op and surgical care as indicated by modifiers appending modifier 54-surgical care only to the surgical CPT code, as well as billing the pre-op care by billing another claim with modifier 56- preoperative management only to the surgical CPT code. Then your provider could bill the surgical CPT code with modifier 55-postoperative care only.

Then your provider gets paid for the work that they put into managing the patient's postoperative care.
 
If there was no formal transfer of care, you would generally code the E&M (and how you only get to level 3 is beyond me, would almost always reach a level 4).
If there was a transfer of care, you would bill the ORIF code with a Post-Op Care Only modifier 55
 
1. You can call the other practice to see how they billed (good luck depending on the size, etc of that practice and if they have an internal or external billing company). I highly doubt they billed it correctly with a 54. If they billed the global but did no post op care, they got paid for the entire package inappropriately. A. They either billed it correctly with a 54 knowing the patient would go back home for post op and did a transfer of care. OR B. They billed the global with no modifier. If they already billed it and you are trying to get them to correct it to a 54, good luck with that.
If they did somehow follow the proper procedure/transfer of care and appended a 54, your local provider would bill the exact same codes as them with modifier 55 to be paid for the post op care. The patient would then be in a global with you and any further follow ups post op would be 99024. I have seen where the surgical office did not code correctly according to the op note and then the local codes correctly and mishaps occur.

As stated above,tThe local provider would bill E/M for the care they are giving now even though it is post op, they got zero credit for the surgery if the 54/55 method was not done.


Very common in ortho trauma in tourism areas like ski resorts, mountain biking, etc.
 
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