Wiki Transfer of Care Question

[donsgirl1015]

I have a patient who had a fracture & surgery out of state, has returned home for follow up care. I know that I need to bill the surgery code with -55modifier.
my questions are
1) can my provider ALSO bill a new patient E&M on the 1st visit?
2) if I DO NOT have any written transfer papers from the operating surgeon office, do I bill only e&m codes as the patient comes in for f/up care?
3)I have been unable to get any assistance from surgeons office as to information on their claim to know if it was billed with the -54modifier or not

suggestions? information? thank you!
melissa

 

[jamierenay]

If the provider is seeing the patient for the first time i would think you should bill a new patient visit. Since you are seeing the patient for the follow up care only you would append modifer 55 to your visits. You will need to get those surgical records to see what Cpt code was performed so you know the global days.

 

[donsgirl1015]

is it appropriate to put the -55mod on 99203? I thought that was only for surgical codes ~

and, I have the medical records, so I know what code should have been billed for the surgery, I just can't get any info from their billing dept to know if they used the surgical svc only modifier.

concerned about billing a -55modifier without supporting documentation

 

[mitchellde]

You do not append the 55 modifier to E&M codes. You would bill the surgical code with the 55 modifier. You will not use both the new pt E&M and the procedure +55. one or the other. The correct way is to use the procedure with the 55. However you do need a written transfer of care. You may need to contact the payer to inquire how it was originally submitted.

 

[CodingKing]

E&M is part of the post-op care and is global to the surgery code. According to NCCI being a new patient alone does not qualify for billing of a separate E&M. As mentioned above transfer of care needs to be documented.

 

[donsgirl1015]

thanks!!! this is coming into focus ~ one more follow up question...
is this scenario similar to the choice the physician has when treating a fracture - in that he could bill a global fracture care code OR bill office visit, casting, xrays for each visit the patient has?

OR - is it that the cpt code with -55 is THE WAY to bill this situation?

Thank you very much!!!!

 

[CodingKing]

thanks!!! this is coming into focus ~ one more follow up question...
is this scenario similar to the choice the physician has when treating a fracture - in that he could bill a global fracture care code OR bill office visit, casting, xrays for each visit the patient has?


OR - is it that the cpt code with -55 is THE WAY to bill this situation?


Thank you very much!!!!

If its not expected to be a one and done visit, the fracture care code must be billed. Initial casting is included in the fracture care code. As far as I know the x-rays are separately reportable even if global fracture care is provided. Billing OV to get around dealing with the Global issue with the other provider would be misrepresenting services. The other physician billing for global fracture care when only performing pre-op and interop would be inappropriate billing as well.

 

[mitchellde]

you need to look up alternative fracture billing. For simple nondisplaced fractures you can elect to bill as not global fracture care, by billing an OV plus casting and then OV for each follow up encounter. If you use alternative method then modifiers are not an issue. ERs many times use alternative for simple fractures that are set in the ER and followed up later in the office.
from the AAPC website:
How Do You Bill Fracture Fees?

There are two common approaches when coding non-manipulative fracture care services. The American Academy of Orthopaedic Surgeons (AAOS) and the American Medical Association (AMA) support these two approaches. The AMA has published several articles in CPT® Assistant to reflect how these options work. The two options are:
Fracture global fees
Alternative method for fracture fees

The AAOS Guide to CPT® Coding for Orthopaedic Surgery definition of fracture global fees reporting method states:

“Fracture global fees may include the hospital or office encounter in some payment areas. In others, CMS allows you to code an E/M service with a -57 modifier [Decision for surgery] within the global period if the visit was the one in which the decision to perform the procedure was made. The initial cast or splint is applied, and all revisits, excluding radiographs that are obtained by the physician, should be included within a 90-day period from the time of the initial fracture. All recastings and or splinting are on an ‘encounter’ basis and are separately billed.”

AAOS defines the alternative method as such:

“Only when treatment of the fracture does not consist primarily of a ‘procedure’ (for example, closed treatment without manipulation), services may be itemized as if the problem were recognized as an office encounter. Examples include an undisplaced fracture of the fifth metatarsal; a fracture of the pelvis, undisplaced or minimally displaced; or a compression fracture of a vertebra. Office, hospital, and emergency department encounters are coded as appropriate, as are all injections, supplies, casts, splints or treatment program necessities.”