General Surgery Coding Alert

Because most surgeries have a built-in global period that includes postoperative procedures in the fee for the original surgery, getting reimbursed for providing such post-op services for a patient whose procedure was performed by another surgeon can be difficult. But complete communication between the surgeons offices is the key to getting paid for providing post-operative care to such patients.

The global period is supposed to apply only to routine follow-up after surgery, though some private payers interpretations may be considerably broader. Routine follow-up typically means managing the patients recovery from surgeryfor example, making sure the wound heals without infectionnot for treating any other condition the patient has or may develop.

When one surgeon takes over routine management of the patient after an operation by another, both surgeons are supposed to share the reimbursement for the procedure. To inform the payer about the arrangement, the surgeon who performed the procedure bills it with modifier -54 (surgical care only), while the surgeon providing postoperative care bills the same procedure code with modifier -55 (postoperative management only) appended. The payer then divides payment between the two surgeons. According to Medicare guidelines, a percentage (usually 85-90 percent) of the procedures fee goes to the surgeon who performed the operation, and 10-15 percent is allotted to the surgeon providing post-op management.

For the reimbursement to be divided correctly, however, the offices of both surgeons must arrange a transfer of care in writing and coordinate billing so that the modifiers are used correctly.

Overcome Global Period Obstacles

Unfortunately, it doesnt always work that way. Problems often arise because the physician managing the post-op care may not be aware the patient is in a global period. And the operating surgeon may not know the patient will not follow up with him or her but rather will visit a surgeon closer to home after being released from the hospital.

For general surgeons, splitting the global fee between intra- and postoperative care occurs when:

the patient requires surgery when he or she is out of town. The operation is performed by a general surgeon in the location being visited, but once the patient is well enough to return home, he or she will see a local general surgeon for routine postoperative care.

the patient lives in a rural area where the service required is unavailable, so he or she travels to a full-service hospital many miles away. Once the surgery is performed, the patient returns home and visits a local surgeon for post-op treatment.

Although these two scenarios have much in common, there is one important difference between them. In the second scenario, the surgery likely has been organized ahead of time, giving staff in both offices the opportunity to coordinate billing, as well as the transfer of care from one surgeon to the other. In the first situation, however, the office of the surgeon who will manage the patients post-op care cannot make arrangements ahead of time. In fact, locating the operating surgeon may be difficult, much less coordinating a transfer of care and billing with his or her staff.

If care has not been transferred, however, or if the operating physician does not attach modifier -54 to the procedure when it is billed, the surgeon providing post-op care may have significant problems getting reimbursed because Medicare and third-party payers will reimburse only one surgeon for rendering routine postoperative care. And it is up to the surgeon providing postoperative care to locate the operating surgeon, obtain a transfer of care in writing and coordinate the correct use of modifiers.

Managing the patient after the surgery is not enough to get paid for it, says Janine Valentine, CPC, senior coder with Facey Medical Foundation, a multispecialty group of 109 providers, including four general surgeons, in Mission Hills, Calif. You have to have a transfer of care documented in the hospital notes or patients chart before you take over the treatment, she adds.

Coordinating the Patients Post-op Care

So communication between offices is critical, as is documentation that indicates when the surgeon managing the patients post-op care took over, Valentine says.

For example, a patient who is traveling requires an immediate hernia repair (49560, repair initial incisional or ventral hernia; reducible). A surgeon located in the area where the patient is traveling performs the procedure but obviously will not be managing the post-op care. The operating surgeon should transfer care of the patient to the patients surgeon back home, leaving a clear note to that effect in the patients chart, and bill for the procedure as 49560-54. When the patient returns home, the local surgeon notes the day postoperative care began and reports his or her services to the carrier using the same code but with modifier -55 attached.

The carrier then computes a percentage of the allotted payment within the 90-day global period. In the case of the hernia repair, the total payable amount of the fee is approximately $600. Of that, $540 (90 percent) would go to the operating surgeon for performing the operation and the pre-op care, and $60 would be paid to the surgeon managing post-op care.

The post-op care surgeon treating the patient who suddenly required surgery while traveling bears the responsibility of locating the operating surgeon to determine precisely which procedure was performed (because the patient is unlikely to know the exact CPT code) and making sure that surgeon documents the transfer of care and uses modifier -54.

If that proves impossible, however, the surgeon performing post-op care should attempt to obtain reimbursement for his or her services in one of two ways, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. If the surgeon knows the procedure performed, he or she may bill for it with modifier -55 attached or charge for an office visit with or without modifier -55, depending on the carrier.

If the surgeon elects to use an evaluation and management (E/M) code, however, providing medical necessity may be a problem because if the diagnosis code links the E/M visit to the surgery, Medicare and other payers may deny the claim on the grounds that post-op care has been billed by the operating surgeon (who didnt transfer care in writing and didnt bill with modifier -54).

The claim may be rejected upon first submission. On appeal, however, the surgeon should provide documentation that proves he or shenot the operating surgeonactually performed the post-op care. Although some surgeons believe they cant ask for reconsideration of the claim, that is not true as long as they can prove they did the work, Callaway-Stradley says.

PCPs Deserve Payment Too

Similarly, surgeons should note that if they hand off post-operative care to a primary care physician (PCP), they should not expect to get paid for that care and should bill the procedure with modifier -54, even if the primary care physician or another specialist also is seeing the patient for an unrelated problem.

For example, a general surgeon may perform gall bladder surgery on a patient and then stop seeing the patient because a primary care physician is monitoring the patient for other problems. In that case, the surgeon shouldnt expect to get paid for the post-op care but rather should coordinate the transfer of care with the PCP and bill the procedure using modifier -54.

After all, Callaway-Stradley says, The physician who does the post-op work should be entitled to reimbursement, not the operating surgeon. If you dont do the work, you shouldnt get paid for it.

Surgeons should remember, however, that if there is no prior understanding of co-management of your patient with the operating surgeons office, no matter what you do on appeal, you still may not get paid. So inter-office communication is the key, Callaway-Stradley says.

Finally, any physician who obtains reimbursement for an undocumented service may be audited at some future date. Consequently, surgeons should think twice about billing for the whole procedure when they only perform the intra-operative portion, cautions Callaway-Stradley.

Note: When different physicians in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group. When a new physician within the practice furnishes the entire post-op care, however, the group must then bill for the surgical care and the post-op care as separate line items with the appropriate modifiers (i.e.,-54 and -55).