Modifier Coding Alert

Published on Wed Jan 28, 2015 PDF

Question: My group only uses modifier 55 with post-operative care. For example, when our physician is on vacation, group X performs a pacer insertion with 33208-54 in her absence. When our physician returns, I code post-op visits with the pacer code and modifier 55. If that patient is in the hospital for a few days after the pacer insertion, I can’t code for subsequent visits because I used modifier 55. Is that correct?

Oklahoma Subscriber

Answer: Correct, you cannot bill the subsequent visits using 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, …). You can, however, report each visit with the surgery code and modifier 55 (Postoperative management only). 

Group X uses modifier 54 (Surgical care only) because they are indicating they are requesting reimbursement for the surgery only and not the 90-day surgical package. They take a lesser reimbursement so that the insurance company pays your group for the post-op care. 

Because your group provides the post-operative care, you use modifier 55. You will bill the procedure code with modifier 55 each time your provider sees the patient. Do not bill for any E/M services.