Question Transfer of Care or not?

[adunlap23]

I am probably making this more complicated than it needs to be, but I want to make sure I am coding the following scenario correctly.

One of our physicians sees a patient for an inpatient hospital consultation. The patent has a finger laceration involving the tendon and septic IP joint. The physician performs arthrotomy and drainage of the finger joint. He documents that he has talked to another surgeon from our practice who will see the patient for follow-up care and plan for a staged reconstruction of the lacerated tendon.

According to CMS guidelines, Transfer of Postoperative care is not covered if "a surgeon opts to transfer postoperative care". Thus, this scenario would not be billed that way?

I'm assuming I would bill the joint arthrotomy and drainage as 26080-54 to indicate the physician is not performing the postoperative care. But then would the second physician just bill regular e/m codes?

 

[adunlap23]

I found the following information from an older AAPC document that helps answer my question a little. It states: "Per Medicare policy, physicians in the same group practice who are in the same specialty must bill and be paid as though they are one physician. When these conditions aren’t met, payment for the post-operative, post-discharge care is split between the two physicians—as long as they agree on the transfer of care. Both physicians must keep a copy of the written transfer agreement in the beneficiary’s medical record.
When there is no transfer of care, services of a physician other than the surgeon may be reported with the appropriate level E/M code. Medicare will separately reimburse properly documented, medically necessary services."

So, my next question is: if both of the physicians are of the orthopedic specialty, but they each have different sub-specialties, would that count as same specialty or not? And would I still apply modifier 54 to the original procedure code if I knew the surgeon was not going to be partaking in the patient's post operative care?

https://www.aapc.com/blog/21903-document-transfer-of-care-to-get-paid-for-post-op-work/

 

[amyjph]

If it's within your same group I wouldn't do 54/55. The patient will be post op global to your group. That's making it wayyyy too complicated to try and 54/55 internally and you can't really even do that I think. The patient is global to the group.

https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00101754

"When different physicians in a group practice participate in the care of the patient and all the physicians reassign benefits to the group, the group bills for the entire global package. The physician who performs the surgery is shown as the performing physician. No modifier is necessary."

The second guy will get credit when he does stage 2 with the 58.

54/55 is more for scenarios where, if your trauma call ortho surgeon saw someone in the ED, takes them to surgery, but the patient was on vacation and is returning home without doing any follow up with the surgeon. The operative guy bills only for the surgery and the "home surgeon" would bill the post op. Good luck though, this was always a huge headache trying to get other practices on board. Most times they just do global and the other guy does E/M.

 

[adunlap23]

If it's within your same group I wouldn't do 54/55. The patient will be post op global to your group. That's making it wayyyy too complicated to try and 54/55 internally and you can't really even do that I think. The patient is global to the group.

https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00101754

"When different physicians in a group practice participate in the care of the patient and all the physicians reassign benefits to the group, the group bills for the entire global package. The physician who performs the surgery is shown as the performing physician. No modifier is necessary."

The second guy will get credit when he does stage 2 with the 58.

54/55 is more for scenarios where, if your trauma call ortho surgeon saw someone in the ED, takes them to surgery, but the patient was on vacation and is returning home without doing any follow up with the surgeon. The operative guy bills only for the surgery and the "home surgeon" would bill the post op. Good luck though, this was always a huge headache trying to get other practices on board. Most times they just do global and the other guy does E/M.

Thank you. You are a huge help!