Reporting the Surgical Relay

Modifiers 54, 55, and 56 come in handy for coordinating care claims

By G. John Verhovshek, MA, CPC

All CPT® procedure codes that include a global surgical package consist of three parts: pre-operative services, intra-operative services, and post-operative care (including all related follow-up visits during the global period). On occasion, however, a physician may provide only a portion of the total care associated with a procedure. For instance, an emergency department (ED) physician may initiate fracture care for an injured patient, while an orthopaedist or other physician will provide follow-up care.

Certified Emergency Department Coder CEDC

In such cases, you may need to apply either modifier 54 Surgical care only or modifier 55 Postoperative management only, depending on which portion of the service your physician provides. Be aware, however, that obtaining compensation with the use of these modifiers—especially modifier 55—poses special challenges.

Physician Cooperation is Essential

When appending modifier 54 or 55, you must coordinate your coding with that of the physician who provides the other portion of care. Failure to collaborate likely results in one physician (usually the physician who provides postoperative care) missing out on reimbursement.

For example, a man falls during an out-of-state hiking trip. A local ED physician performs a complex laceration closure on the patient’s face and arms, for which he codes 13132 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 to 7.5 cm for two wounds on the forehead and cheeks, and 13121 Repair, complex, scalp, arms, and/or legs; 2.6 to 7.5 cm and 13122 Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) for lacerations on an arm. The ED physician instructs the patient to follow up with his primary care physician at home (for suture removal, for instance).

In this case, the ED physician would append modifier 54 to both 13132 and 13121. He would not append modifier 54 to 13122 because it is an add-on code (see accompanying sidebar “Calculate Pre-, Post-, and Intra-Operative Care Payments” for more information). The patient’s hometown physician would report the same codes (13132 and 13121) with modifier 55 to indicate that he provided post-op care only. If, however, the ED physician failed to append modifier 54 to his claim, Medicare would consider the entire service “paid in full” and would not reimburse the hometown physician for postoperative management.

Fracture care provides another common example of when you might encounter such “split” claims. For instance, a Florida woman falls while visiting her daughter in Virginia. The woman reports to the local hospital for an X-ray and consultation with an orthopaedist. The orthopaedist performs an open reduction with internal fixation on the patient’s right wrist. Three days later, the woman boards a plane back to Florida, where her regular physician provides follow-up care.

Ideally, the orthopaedist will report the appropriate fracture care code with modifier 54 and contact the patient’s regular physician in Florida to alert him of the need for follow-up care and coordinated claims submission. The orthopaedist could also report the appropriate evaluation and management (E/M) service and X-ray codes, but without modifier 54. The patient’s Florida physician would then report the same fracture care code with modifier 55.

Consider Low-Level E/M

In reality, of course, the kind of perfect cooperation needed to file accurate modifier 54 or 55 claims rarely happens. In many cases, the physician performing the intra-operative service will submit a claim without modifier 54, leaving the physician providing follow-up care without an option to report his services. Remember, Medicare will pay for the same service (including follow-up care for any given procedure) only one time.

As an alternative to modifier 55, you might report a low-level E/M service to describe follow-up care by a different physician. For instance, for a problem-focused visit to remove sutures placed by the ED physician, the hometown physician in our first example might report 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. As a primary diagnosis, he could cite V58.3x Encounter for other and unspecified procedures and aftercare; attention to surgical dressings and sutures, with secondary diagnoses to specify the location of the lacerations (for instance, 884.0 Multiple and unspecified open wound of upper limb, without mention of complication).

Avoid Modifier 56 for Medicare

In addition to modifiers 54 and 55, CPT® also includes modifier 56 Preoperative management only to describe pre-operative services. However, Medicare does not recognize modifier 56 because it automatically includes preoperative care in the payment to the physician who performs the intra-operative portion of the service.

Side Bar: Calculating Pre-, Post- and Intra-Operative Care Payments

Medicare assigns individual payment amounts for the pre-, post- and intra-operative care portion of each procedure with a global surgical package. You can find these allotments in the Medicare Physician Fee Schedule (MPFS) Relative Value File, available as a free download on the Centers for Medicare & Medicaid Services (CMS) Web site (Medicare updates the MPFS each year, and sometimes several times during the year. Be sure to download the most recent file available).

Among other information, the MPFS contains three columns, labeled PRE OP, POST OP, and INTRA OP. Each column lists a percentage of the total value that Medicare will reimburse for only that portion of the procedure. When added together, the three columns should equal “1.00” (100 percent).

For example, if you look up 63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace in the MPFS, you will find that Medicare allots 11 percent of the total payment allowance for pre-operative care, 76 percent for the intra-operative service, and 13 percent for post-operative care.

If a surgeon reports 63075 with modifier 54 Surgical care only, he will receive 87 percent of the total reimbursement assigned to the procedure (approximately $575 in physician work value, based on current Medicare national average payments). Remember that Medicare does not recognize modifier 56 Preoperative management only, and automatically includes pre-operative care as part of the intra-operative portion of the service.

Another physician successfully reporting 63075 with modifier 55 Postoperative management only will receive the remaining 13 percent in reimbursement, or approximately $87.

Medicare does not specify separate pre-op, post-op, and intra-op values for add-on codes. Pre- and post-operative services associated with add-on procedures are included in the value for the primary procedure code. Similarly, Medicare does not assign separate pre-op, post-op, and intra-op values for add-on codes for those procedures with “XXX,” “YYY”, and “000” (zero) global periods.

You should never append modifiers 54 or 55 to any code that does not include separate pre-op, post-op, and intra-op values.

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