Wiki Surgical package

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MARY K

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I work for orthopedic surgeons who send patients to pcp for pre-surgical clearance. Our problem is one pcp in area is refusing to see our patient(which are some of pcp's own patients) unless we give inteneded surgical codes. According to this pcp they were told by a consultant that now that consult codes are no longer ok to use that the pcp is entitled to part of surgeons surgical package. Is their another surgeons' office having this trouble? Anyone ever heard of pcp doing this? Any advice will be welcome.
 
If you are requesting the PCP perform the preoperative encounter then they are doing the preoperative management of your surgical service at your request so yes they need your surgery code so that they can bill the pre op portion of your global with the 56 modifer and your surgeon will have that amount (approx 10%) deducted from their reimbursement.
 
regarding Mitchellde's comment...what if you are only sending the pt to the pcp for medical clearance? The surgeon's office is taking care of bloodwork/EKG ect..?:confused:
 
That's wild, I did not realize that you could bill like that. We do pre-op physicals at our family practice group. Am I understanding correctly that you could bill the office encounter and a surgical code with mod 56 appended and get paid for both, or would you only bill for the surgical code with mod 56?
 
surgical package

How or what did Pcp office bill before Medicare stopped consult codes. It seems this was never an issue before Jan 2010.Cpc:
 
surgical package

How or what did Pcp office bill before Medicare stopped consult codes. It seems this was never an issue before Jan 2010.Cpc:
 
To be honest a preop encounter was not to be billed as a consult and this was one of the reasons CMS decided to discontinue consultations. The surgeon is not requesting a consult from the PCP they are requesting a medical evaluation. The AMA created the global modifiers years ago as a way to split the surgical global into three distinc parts. If the suregeon requests the preop to be performed by another physician then he is transfering that part of the global to that physician. If the surgeon wishes to perform part of the preop then the PCP can bill using the 56 and the 52.
 
Mitchellde, do you (or anyone else in this post) have a source document for this info? It's very probable I will need to cite something official when I explain this to the specialist offices to get the proper sx codes ;).

This is a very interesting twist to coding pre-op, but I suppose it makes good clean sense.
 
I would like to see some written guidelines for this also.

To me, there is a significant difference in a physician providing the pre-op care (identify, eval, DX, treatment plan, decision for surgery) and a physician doing the pre-op clearance (basically a 2nd look to verify if there is any reason not to proceed with planned surgery).

I do agree that a major misunderstanding was that pre-op clearance automatically meant consult. Not true and a big issue that I suspect will continue with the mon-medicare payers.

56 Preoperative Management Only: When one physician performed the preoperative care and evaluation and another physician performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number.

54 Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.

55 Postoperative Management Only: When one physician performed the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number.
 
The guidelines I found for this a few years back were from the CMS website. The link was saved on a previous computer so I no longer have that. Sorry for that, but you can do a search and find it. The preop can be split between the PCP and the surgeon and each would bill the surgical plus the 56 and the 52. As far as the definition I see no difference in preop clearance and management. Preop is preop not the decison for surgery, the evaluation to determine the need for surgery has already been performed so now all that is left is to evaluate the pre existing conditions and status, which is what the surgeon is requesting from the PCP. Not a consult but a medical determination. I think this is one of those things that has several phrases which all boil down to the same thing.
 
Surgical clearance

Anyone out there may answer this; previous to january 2010 what were pcps' billing when pre-op clearance was requested? The surgeons' already made decision for surgery and talked to patient about pros and cons of surgery pcp or physician is not making any decisions regarding pt surgery; i would like to add that only one pcp office is requesting these codes, we deal with many in area. We really need some documentation to support or shoot this down. We are almost at blows with this pcp office.
 
I have had several PCPS bill using the 56 modifer for several years. This is not something that came about as of January 1 2010, it is just probably more visible now. But think of it this way, after your physician decides that surgery is just the ticket for this patient, if your physician then sees the patient again for preop purposes, it is not chargeable as it is part of the global reimbursement for the surgery. Therefore if your physician requests another physician to perform the preop then that physician should be entitled to that portion of the surgeons global that is attached to the preop, and that is usually 10% of the global allowable. Many years back I had a consultant tell me that the PCP had to charge a consult because an office visit would deny as being part of global. It did not take long for most offices to figure out that a consult would pay even if the service was offered during the surgical preop time. Some things that have been done in the past are not necessarily correct it was just done that way and passed down to be done that way. There is nothing incorrect with what your PCP's office is doing, and with some carriers it may be the only way they can be reimbursed. So do not come to blows, accept that change is not only good, sometimes it is the right thing.
 
We(the surgeon) order pre-op testing which includes labs, bloodwork, ekg, if cardiac clearance is needed we(the surgeon) also set this up. We set up operating room scedule, anesthesia and materials surgeon needs for operation; and we do alot of pre-op in our own office. Please tell me what is left for pcp to do that is worth 10% of our surgical package. The only reason i refer to january 2010 because before this no pcp in are area ever asked for these codes, and only 1-pcp office is asking now
 
In the interest of all involved in this discussion, I have been digging for documentation to support the answers to this question "billing for preop with modifier 56".
So far, after sorting through CMS guidelines, AAFP, CPT Assistant, and various other sources this is where I am at so far:
1 - If the service has met the requirements for a consultation, then you would bill the appropriate level consult (unless billing Medicare for 2010)
2 - If the service does not meet consultation requirements (or you are billing Medicare), you would bill the appropriate level E/M 99212-215 or 99201-205.
I have found many references to modifier 56 being billed in coordination with the sx code from the surgeon - BUT - There is no clear indication on what to base billing a surgery code with mod 56 over an E/M service.
I am very interested to find this missing piece, as this could greatly affect the way we code preop visits. If anyone finds a source document to unravel all this, please let us know :p Until then, I will keep digging.
 
I am not finding where CMS or payers will even pay separately for -56

Here are some pastes.......

Non-Medicare payer:
Consistent with the Centers for Medicare and Medicaid Services (CMS), payer considers the surgical care rendered by a physician or other health care professional to include pre-operative management.

Accordingly, in split surgical package situations, the pre-operative and surgical care portions of the surgical package are combined in the reimbursement of surgical codes appended with modifier 54. Pre-operative care is not reimbursed separately.

Post-operative care management may be reimbursed separately when a physician or other health care professional who is not within the same group practice as the operating physician provides the post-operative care as denoted by submission of the surgical code appended with modifier 55.

Split surgical package situations will be reimbursed not to exceed 100% of the total global surgical allowable amount, and are reimbursable at the percentages indicated as follows:

Modifier Modifier Description Percentage
54 Surgical care only (includes pre-operative and surgical care management) 80%
55 Postoperative management only 20%
56 Preoperative management only 0%
. TOTAL 100%

Medicare/CMS addresses split services (begins on page 87) of this link. They dont address -56 as it is not paid alone

https://www.cms.gov/manuals/downloads/clm104c12.pdf

Another CMS reference states (its older). See page 5-6 of this link

http://www.cms.gov/transmittals/downloads/R1707B3.pdf

B. Non-global Preoperative Services.--Consist of evaluation and management (E/M) services (preoperative examinations) that are not included in the global surgical package and diagnostic tests performed for the purpose of evaluating a patient's risk of perioperative complications and optimizing perioperative care. Medicare will pay for all medically necessary preoperative services as described in §15047, subsections C and D.

C. Non-global Preoperative Examinations.--E/M services performed that are not included in the global surgical package for the purpose of evaluating a patient's risk of perioperative complications and to optimize perioperative care. Preoperative examinations may be billed by using an appropriate CPT code (e.g., new patient, established patient, or consultation). Such non-global preoperative examinations are payable if they are medically necessary and meet the documentation and other requirements for the service billed.


For me, when another Physician does the the pre-op clearance, they code the appropriate OV code with DX V72.8x with a 2nd code for the surgical condition. I have never coded or seen the pre-op clearance coded with the CPT-56

Also, just side note: just because this one office wants your surgical CPT codes, how many times has the surgeon gone in and ended up doing something different or more than he planned? Are they expecting you to call them back and say "he didn't do a lap xxx he ended up doing an open xxx". This would be an absolute nightmare to follow (at least on their end).
 
Sbicknell and coder*911 thanks for the info. We have 4-coders at this office and we have gone over and over this with the same conclusions you guys confirmed. We have even approached pcp office coder to coder but they claim a consultant told them this. Just want to say thanks again from binghamton, ny; thelma cpc
 
I will see if I can bring it up again but I had a letter from BCBS from a couple of years ago where they were instructing the PCP to use the 56 modifier. I will try to bring it up again for you. This is not a perfect world and not all carriers do the same things, but as I stated previously it is a correct way to bill.
 
Here is a couple of things from the payers:
This is BCBS
Modifier 56 – Preoperative Management Only
•
Modifier 56 is reported when one physician performed the preoperative care and evaluation and another physician performed the surgical procedure. Modifier 56 is appended to the surgical code. The physician is paid a portion of the global package.
•
Modifiers 56 should only be appended to the surgical procedure codes.
•
Procedure codes with modifier 56 appended will price at 15% of the allowable charge.
This is Regents
The Centers for Medicare & Medicaid Services (CMS) designate which procedure codes are valid for use with “split-care” modifiers -54, -55 and -56. The Regence Group (TRG) utilizes these CMS designations in determining procedure code/modifier combinations that are valid for TRG use. In the absence of a CMS modifier -54, 55 and/or 56 indicator, TRG may establish a modifier -54, 55 and/or 56 designation.
The total reimbursement for a surgical procedure is the same regardless of how the billing is split between the different providers involved in the patients care.
Correct coding guidelines require that when the components of a global surgical package are performed by different physicians, the same surgical procedure code (with the appropriate modifier) be used by each physician to identify the services provided. The intra-operative and post-operative services should be billed with the date of the surgery as the date of service.
A surgeon performing only the surgical component of a global surgical package (with another physician providing the postoperative care) must attach modifier -54 to the surgical procedure code.
A physician providing only the postoperative component of a global surgical package (with another physician
performing the surgical procedure) must attach modifier -55 to the surgical procedure code. An E&M visit code is not appropriate to use in this situation.
A physician providing only the preoperative evaluation component of a global surgical package (with another physician performing the surgical procedure and postoperative care) must attach modifier -56 to the surgical procedure code. An E&M visit code is not appropriate to use in this situation.
Just to give you another side of the story.
Also the 2009 modifier guide from CMS
www.medicarenhic.com/providers/pubs/Modifiers Guide.pdf
 
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modifier 56

I don't believe this is correct. The PCP's office has only been asked for medical clearance on a surgery patient. The surgeon's office sets up all the tests, ekg, lab work, etc. The surgeon's office does all that, not the PCP. The PCP is simply doing an office visit 2 wks prior to the surgery date for medical clearance. That is an E/M visit, not a pre-op visit. The surgeon's office does all the work-up for the patient, makes all the arrangements. The surgeon should be paid for pre-op.
NGS Medicare states this is incorrect and a non-compliant practice.
If the PCP was handling all the Pre-op work, then I may consider agreeing with mitchellde, but they are not and should not be, since the surgeon's office is handling all that.
 
ortho65 said:
I don't believe this is correct. The PCP's office has only been asked for medical clearance on a surgery patient. The surgeon's office sets up all the tests, ekg, lab work, etc. The surgeon's office does all that, not the PCP. The PCP is simply doing an office visit 2 wks prior to the surgery date for medical clearance. That is an E/M visit, not a pre-op visit. The surgeon's office does all the work-up for the patient, makes all the arrangements. The surgeon should be paid for pre-op.
NGS Medicare states this is incorrect and a non-compliant practice.
If the PCP was handling all the Pre-op work, then I may consider agreeing with mitchellde, but they are not and should not be, since the surgeon's office is handling all that.
Click to expand...
It can be modified to show partial with the 52 so it would have both the 56 and the 52 it is not noncompliant.
 
All of us obviously have some very interesting opinions on this matter. Which really proves how difficult coding can be - when other experienced CPCs can't completely agree on a subject. I am extremely glad this subject came up because I never even considered billing pre-op this way until now - BUT - being the suspicious/paranoid coder that I am, I need some kind of documentation to validate either case. I haven't found any concrete evidence to say that you can't bill a sx code with mod 56, and I haven't found any evidence to support not billing it either. I have, however, found documentation to support billing the office visit codes. I think until someone can provide the documented rules for billing pre-op, it all becomes speculation and opinion.
I would like to clarify with ortho65 if possible - If our family practice group performs all the xrays, ekgs, labs, and evaluation for the pre-op does this qualify as the pre-op care? Or is there another component to this that I am not aware of? I just want to make sure I understand the surgeon's side of the workup. As I posted earlier, this could really affect our billing - so we need to move carefully on this.
Thank you.
 
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