Orthopedic Coding Alert

Question: Our orthopedic surgeon is seeing a patient for follow-up visits after care from another physician. We’re billing office visits, but Medicare denies the claims even when we included modifier 55 for postoperative management only. How should we handle this situation?

Alabama Subscriber

Answer: Verify the surgical procedure and CPT® code reported by the initial surgeon so you can include the same code on your claim with modifier 55 (Postoperative management only) attached to that surgical code. Your physician should be paid approximately 20 percent of the allowed amount for the primary CPT® code reported. Warning: You may find yourself in a quagmire when trying to do this, because the operating surgeon rarely applies modifier 54 (Surgical care only) to the surgical CPT® code. Reporting post-op management in this manner requires coordination with the operating surgeon’s office.

No E/M code: Postoperative visits related to the surgery are included in the surgical procedure code, so don’t bill an office visit such as 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). That’s why you’ll submit your claim with the original surgical code and modifier 55. The insurance company may be saying that they paid the original MD 100%, including the 20% post-op care. Many practices have had this occur. Your appeal should mention that the 20% should properly be paid to the new treating physician.

Caution: CPT® includes 99024 (Postoperative followup visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure) for related postoperative visits within the global period. Although your orthopedist is seeing the patient postoperatively, don’t report 99024 -- it’s reserved for postop visits with the operating surgeon.