Keep Your Surgical Services Reporting Compliant

Keep Your Surgical Services Reporting Compliant

Look to modifiers 54 and 55 when providers split global package services.

Modifiers 54 Surgical care only and 55 Postoperative management only can help alleviate a common billing dilemma. If you have worked in an orthopedist’s office or coded for emergency room (ER) services, you likely know about the silent feud between these two specialists. Many orthopedic (ortho) providers feel ER providers should always consult ortho on fractures and only stabilize the patient and then transfer care. This would prevent numerous billing issues for both providers such as improper payments and denied claims. Alternatively, you can ensure billing compliance for all parties with proper use of modifiers 54 and 55.

Surgical Global Periods Cause Conflicting Interests

A patient’s fracture can be repaired in the ER, and the ER doctor can treat and bill for this service, as long as they document their work appropriately. According to the American College of Emergency Physicians (ACEP), closed fracture treatments ER providers can perform include:

  • Closed treatment of fracture without manipulation (e.g., 23500 Closed treatment of clavicular fracture; without manipulation)
  • Closed treatment of fracture with manipulation (e.g., 26755 Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each)
  • Closed treatment of dislocation with fracture with manipulation (e.g., 23665 Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation)
  • Closed treatment of dislocation without fracture, with manipulation (e.g., 23650 Closed treatment of shoulder dislocation, with manipulation; without anesthesia)

These procedures have a global period and a global package; this means that, when performed, the billing provider will be paid for the procedure as well as pre- and postoperative services. The provider will receive one bundled payment for the services included in the global package (preoperative services, the procedure, and postoperative services). The global period is from the provision of preoperative services through postoperative services. Depending on the procedure, the global period can be 0 days, 10 days, or 90 days. The Centers for Medicare & Medicaid Services (CMS) defines these global periods as follows:

0 days – Endoscopic and minor surgeries with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount.

10 days – Minor surgical procedure with preoperative relative values on the day of the procedure and a postoperative relative value during a 10-day postoperative period is included in the fee schedule amount.

90 days – Major surgical procedure with a 90-day postoperative period is included in the fee schedule.

But what if more than one physician was involved in treating the patient?

Orthopedists argue that the ER should not be paid the global fee when they are not doing all the work included in the payment of the CPT® code billed. If a patient sees an ER provider for fracture treatment and then they see an orthopedist within the same healthcare system, the claim for ortho will likely be denied. The orthopedic services are not separately reimbursable because they’re being done within the global period. When this happens, the orthopedist loses money. However, the ER provider did perform services and should be reimbursed, as well. How can we fix this?

Modifiers 54 and 55 Resolve the Conflict

We can overcome this dilemma by educating ourselves on the use of modifiers 54 and 55 and how they can enable us to properly code for the surgical services being provided. Once we educate ourselves, we can then educate providers and clinical staff. And when we work within the same healthcare system, we should also work across specialties.

When the ER provider is just stabilizing a dislocation or fracture, it should be clearly documented so that only the application of the cast, strapping, or splint is coded. The codes for splints and strapping should be used when the provider is applying them to stabilize, protect, or alleviate the patient’s pain. To capture these services, there must be documentation that the provider personally applied the splint or strapping.

When a nurse is doing the stabilization, always check with your payer regarding coding the application as incident-to (office) or split/shared (facility) services. Many times, if nursing staff performs the stabilization, it is not reimbursed on the professional side of coding/billing.

If casting, strapping, or splinting is used as part of restorative care, we should use the appropriate fracture care code, and not code the stabilization with the fracture treatment, as this would be erroneous unbundling that could lead to improper payment. Bill one or the other based on the documentation. When the fracture is stabilized for patient comfort or to protect from further damage until they see the orthopedist, use the casting, strapping, or splint CPT® code. This way, the orthopedist is not affected by any global package issues and they can bill for their services appropriately.

Modifier 54

When an ER doctor provides restorative care and a significant portion of the global fracture care, they should report the appropriate fracture treatment care CPT® code and append modifier 54 Surgical care only. Modifier 54 indicates one physician performed a surgical procedure and another provided preoperative and/or postoperative management.

ER providers only see a patient once for a fracture; they do not follow up on the patient’s progress. As such, they are only providing one part of the global package for that CPT® code. Appending modifier 54 to the CPT® code lets the payer know the ER provider only completed the surgical portion of the CPT® code they are reporting and to reimburse them at a lower rate. Doing so also makes them aware that another claim will be submitted from another specialist for the postoperative services.

Modifier 55

How should the orthopedist submit their claim if they only provided postoperative care and did not perform other services for the patient? The orthopedic specialist would see the patient, document their services accordingly, and submit a claim with the fracture treatment code, which can be the same as what the ER submitted or different depending on the documentation, appending modifier 55 Postoperative management only to the code. If the orthopedist did other services, those services should be captured for reimbursement, as well.

Modifier 55 is for postoperative management only — when one provider performed only the postoperative care for the patient. In cases where the orthopedist did not provide preoperative care or the surgical procedure, they should use modifier 55 to inform the payer that they should only be reimbursed for the postoperative portion.

Note: It’s always good to check with your local payers on the use of modifiers 54 and 55; each payer has its own regulations and guidelines. You can find the global days for CPT® codes on the CMS website (listed in references).

Communication Is Key

When ortho and the ER are part of the same group or healthcare system, communication is the key to having both specialists’ claims sent out correctly and reimbursed appropriately. This applies to any two specialties and many other operative services, not just fracture treatment. We should be working together to ensure accurate claim submission and proper reimbursement for both parties.


Resources:

CMS. Global Surgery Booklet, September 2018 (Retrieved May 2019)

CMS. Global Surgery Data Collection, December 2018 (Retrieved May 2019)

ACEP. Orthopedic Fracture / Dislocation Management FAQ, May 2015 (Retrieved May 2019)

Grider, Deborah J. Coding with Modifiers; A Guide to Correct CPT and HCPCS Level II Modifier Usage. AMA. 2006

Tammy Vannatter-Berger
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Tammy Vannatter-Berger, BHSA, CPC, CMA (AAMA), RMA (AMT), has worked in healthcare for 25 years, currently as a coding manager for a Metro-Detroit healthcare system. She teaches coding and billing online for a local college, as well. Vannatter-Berger is on the 2022-2023 AAPCCA BOD and has held a variety of officer positions in the Macomb Township, Mich., local chapter.

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