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Proper Billing of Surgical Comanagement (Modifiers 54 and 55)

Medicare covers surgical comanagement for appropriate reasons such as inability of the operating surgeon to provide postoperative care, inability of the patient to return to see the operating surgeon in the postoperative period for a variety of reasons or patient preference. For example, one physician may perform the surgery, but another physician may provide the follow-up care. Medicare will pay no more than the total fee schedule approved amount for the surgical procedure regardless of the number of physicians involved. Comanaged care should always adhere to good patient care, the ethical responsibilities of providers and governmental rules.

When physicians agree on the transfer of care during the global period, use the following modifiers:

  • 54 for surgical care only.

Or,

  • 55 for postoperative management only.

Providers do not need to specify on the claim that the care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field NTE segment on the claim form (Item 19). Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. (CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2).

When a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until at least one service has been provided. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which care of the patient has been assumed. The exact number of postoperative days should be given in Item 24G of the CMS-1500 claim form or electronic equivalent.

Exceptions:

  • Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate evaluation and management code. No modifiers are necessary on the claim.
  • If the transfer of care occurs immediately after surgery, the physician other than the surgeon who provides the in-hospital postoperative care bills using subsequent hospital care codes for the inpatient hospital care and the surgical code with the 55 modifier for the post-discharge care. The surgeon bills the surgery code with the 54 modifier.
  • Physicians who provide follow-up services for minor procedures performed in the emergency department should bill the appropriate level of office visit code. The physician who performs the emergency room service bills for the surgical procedure without a modifier.
  • If the services of a physician other than the surgeon are required during a postoperative period for an underlying condition or medical complication, the other physician reports the appropriate evaluation and management code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.

Date(s) of Service

Physicians, who bill for the entire global surgical package or for only a portion of the care, must enter the date on which the surgical procedure was performed in the “From/To” date of service field. This will enable carriers to relate all appropriate billings to the correct surgery. Physicians who share postoperative management with another physician must submit additional information showing when they assumed and relinquished responsibility for the postoperative care. If the physician who performed the surgery relinquishes care at the time of discharge, he or she need only show the date of surgery when billing with modifier 54.

However, if the surgeon also cares for the patient for some period following discharge, the surgeon must show the date of surgery and the date on which postoperative care was relinquished to another physician. The physician providing the remaining postoperative care must show the date care was assumed. This information should be shown in Item 19 on the CMS-1500 paper form , in the narrative portion of the electronic claims.

Care Provided in Different Payment Localities

If portions of the global period are provided in different payment localities, the services should be billed to the Medicare contractor servicing each applicable payment locality. For example, if the surgery is performed in one state and the postoperative care is provided in another state, the surgery is billed with modifier 54 to the contractor servicing the payment locality where the surgery was performed, and the postoperative care is billed with modifier 55 to the contractor servicing the payment locality where the postoperative care was performed. This is true whether the services were performed by the same physician/group or different physicians/groups.

55 Modifier Postoperative Management:

Different physicians performs the postoperative management of the surgical procedure.

Use the 55 modifier when one physician performs the postoperative management and another physician has performed the surgery. Use this modifier for “follow-up” physician’s claim and attach it to the surgical procedure. If the postoperative period is “split” or “comanaged,” then both the performing surgeon and the treating “follow-up” physician should bill with the surgical procedure code and use this modifier to report their follow-up care. The performing surgeon should also report on a separate line for the surgical CPT with modifier 54 for the “surgery-only” charge. To obtain the percentages applied to the surgery-only procedure (modifier 54) and the total follow-up percentage (modifier 55), view the Medicare Physician Fee Schedule Data Base. The exact number of postoperative days should be given in Item 24g of the CMS-1500 claim form or electronic equivalent.

Related Content

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2 (1 MB)

Proper Billing of Surgical Comanagement (Modifiers 54 and 55)
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