- Anesthesia Modifiers
- Appropriate Usage of Modifier 99
- Assistants at Surgery at Teaching Hospitals
- Bundled Services Missing Appropriate Modifiers at Time of Initial Claim Submission
- Clarification for Billing Services on Fingers and Toes Using Modifiers F1-F9, FA, T1-T9 and TA vs. Modifier 50
- Correct Usage of Modifier 79 for Multiple Procedures
- Co-Surgery/Team Surgery/Assistant Surgery Modifiers
- Modifier 25
- Modifier 33
- Modifier 51
- Modifier 52 Claim Submission Billing Reminder
- Modifier 59 and the Subset Modifiers XE, XP, XS, XU - Specific Modifiers for Distinct Procedural Services
- Modifier 90 Reference to Outside Laboratory
- Modifiers
- Modifier Usage
- Proper Billing of Surgical Comanagement (Modifiers 54 and 55)
- Proper Use of Modifiers 59 and 91
- Reminder for Submission of Modifier 22
- Repeat Procedures - Modifiers 76 and 77
Proper Billing of Surgical Comanagement (Modifiers 54 and 55)
Table of Contents
- Proper Billing of Surgical Comanagement (Modifiers 54 and 55)
- Exceptions
- Date(s) of Service
- Care Provided in Different Payment Localities
- 55 Modifier Postoperative Management
- Critical Care
- Related Content
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. Using the electronic format, the information must be entered in Loop 2300 DTP03 or Item 19 of the CMS-1500 claim form. 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.
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 E/M 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 the surgical procedure was performed in the “From/To” date of service field. This will enable Medicare contractors 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, and 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 perform 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. Use the Fee Schedule Lookup Tool to obtain the percentages applied to the surgery-only procedure (modifier 54) and the total follow-up percentage (modifier 55). Item 24g of the CMS-1500 claim form or electronic equivalent should be reported as 1 unit when modifier 55 is billed for postoperative management. The key to pricing for this service is the assumed and relinquish date for services provide that is identified in item 19.
Critical Care
If a surgeon fully transfers care and the critical care is unrelated, use the appropriate modifier to show the transfer of care. Surgeons will use modifiers 54 (surgical care only) or 55 (postoperative management only) on their claims. When transfer of care is accepted, add both modifier 55 and modifier FT to your claim. Medical record documentation must support the claims.
Related Content
Reviewed 10/2/2024