Cardiology Coding Alert

Learn which of these modifiers Medicare doesn’t recognize.

Many cardiology procedures have global periods limited to the day of surgery, so you may not have spent a lot of time learning the rules that apply to longer global periods. But understanding use of modifiers 54, 55, and 56 ensures proper reimbursement if your cardiologist ever provides only a portion of the global package. 

Read more about modifiers 54, 55, and 56 so your claims accurately depict the encounters to your payers.

Modifiers Help You Tell the Shared Surgical Care Story

When two physicians provide services within the global surgical period, you can use modifiers to show there has been a transfer of care.

How it works: When the surgeon performs only the surgery and a physician other than the surgeon furnishes pre-operative and/or post-operative care, you will use the following modifiers to explain the division of services:

• 54, Surgical care only
• 55, Postoperative management only
• 56, Preoperative management only.

When you attach modifier 54 to a claim, you’re telling the payer that your physician performed only the surgery, not the pre- or post-operative care. If your physician only performs the postoperative services, you will attach modifier 55 to the procedure code. If your physician performs only pre-operative services, you’ll use modifier 56.

Caution: The descriptions above show the basics of the modifiers, but they don’t take into account payer rules. As explained later, payers typically include preoperative care in the surgical care payment, so use of modifiers 54 and 55 is far more common than use of modifier 56.

Review This Modifier 55 Example

The most common example for using 54 and 55 is a vacationing patient who requires surgery and returns home for the postoperative care. Other examples might relate to the need for a specialist or a surgeon who is unable to complete post-operative care.

Example: A rural cardiologist sends his patient to an academic institution’s cardiothoracic surgeon for a procedure with a 90-day global. Following surgery, the cardiothoracic surgeon returns the patient to his local cardiologist for postop care. The surgeon should report the surgical code and attach modifier 54. The cardiologist will report the same procedure code and attach modifier 55.

Connect with the Other Practice 

For you to use the right modifier when another practice provides a portion of the surgical care for one of your patients, you have to connect with that other practice. You need to make sure that both physicians’ offices coordinate the postoperative care and enter the number of postop care days that they each see the patient and submit the services on separate claim forms. The surgeon in the scenario above may want to see the patient for at least the initial postoperative days before turning over the care to the rural-based cardiologist, for example.

“The largest hurdle regarding these modifiers is knowing the other office,” stresses Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC, manager of physician compliance auditing at Allegheny Health Network in Pittsburgh, Pa. “If your physician did the surgery but won’t be following the patient as she’ll be going to recover at her son’s house in another city, then in order to bill correctly, you should communicate with that office. You would then bill for the pre-op and surgery, the other office would bill for the postop care; everyone would use the same surgery CPT® code instead of E/M service codes for the postop care.”

Another, more complicated, hurdle may be when the patient expresses dissatisfaction with a physician and requests a different one. For example, “If the patient had the surgery by Dr. A and did not like her, the patient would rather be followed by a different physician in a different group for his post-op care, the communication between the two offices might not be as straightforward,” continues Hauptman. “Dr. A might not know that the patient isn’t following with her. Dr. B might not know where the surgery was originally done or how to get in contact with Dr. A’s office.”

Red flag: If you’re reporting the postop care with modifier 55, you need to make sure the physician who performed the surgery reports the surgery with modifier 54. If you don’t, the payer will deny your claim because they may have already reimbursed the surgeon for the full care associated with the code.

“This is where communication between offices is critical. If one of the offices mistakenly forgets to append a modifier, a corrected claim can be sent in to the health plan in order to ensure proper payments to both offices,” says Betty A. Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD, director, ICD-10 Development and Training at AAPC in Salt Lake City.

Find Out What Your Payers Accept

When payers receive claims with modifiers 54, 55, or 56, they split the surgical package payment between different providers instead of paying the full package amount to one provider. 

Each payer has its own guidelines for the amount it will reimburse each provider. Payers typically pay a percentage of the full payment to each provider, with the highest percentage paid to the provider who rendered intraoperative services.

For Medicare, check the physician fee schedule to see the percentages Medicare applies to the particular code. As an example, 33208 (Insertion of new or replacement of permanent pacemaker with transvenous electrode[s]; atrial and ventricular) has a 90-day global period. The physician fee schedule indicates preoperative work accounts for 9 percent of payment, intraoperative for 84 percent, and postoperative for 7 percent.

Warning: Don’t assume that because Medicare shows a percentage for preoperative work that Medicare will reimburse that portion separately. If you are reporting the service to Medicare and use modifier 54, your physician will receive the preoperative reimbursement, too, because Medicare includes it in the payment. This explains why Medicare doesn’t recognize modifier 56. 

Follow Rules to Help Claims Sail Through 

Jurisdiction: Experts advise that if the surgeon and the postoperative care physician perform services in the same Part B contractor jurisdiction, they should both submit their claim to the same MAC. If the services take place in different jurisdictions, the surgeon should send his claim with modifier 54 to the MAC who covers the area where the surgery is performed. The doctor who performs postoperative care should bill the claim with modifier 55 to the MAC that covers the area where the postsurgical care occurs.

DOS: Medicare instructs physicians to use the same date of service (DOS) and code for the surgical care only and the postoperative care only. The modifiers will define which portion of the service you’re reporting. Use the remarks field to indicate the transfer of care date, and keep the written transfer agreement on file.

Immediate transfer: In cases where the surgeon hands over care immediately after surgery, meaning a different physician provides in-hospital postoperative care, the surgeon should use the surgery code and modifier 54 and the postop physician should report the surgery code with modifier 55 as well as subsequent hospital care codes, Medicare instructs.

Resource: Review the information in Medicare Claims Processing Manual, Chapter 12, Section 40, to see the rules straight from the source.