Part B Insider (Multispecialty) Coding Alert

Published on Wed Nov 12, 2003 PDF

Global period may not apply to nonsurgeons, but ethical standards do

If a surgeon hands a patient off to a nonsurgeon right after surgery, the nonsurgeon could be helping the surgeon overcharge Medicare.
 
When a surgeon doesn't provide any postoperative care himself, he should bill for the surgery using modifiers -54 (Surgical care only) and -56 (Preoperative management only) to indicate he only performed preoperative care and surgery, not post-op care. Then, if a nonsurgeon, such as a primary-care doctor or a cardiologist, takes over the patient, she should use the surgical code plus modifier -55 (Postoperative management only) for post-op care.
 
But what usually happens is that the cardiologist or primary-care doctor will simply bill for a few evaluation and management visits, and the surgeon will receive the full payment for the surgery. "The payer ends up overpaying," says Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, N.J.
 
Not only is this common practice wrong but it could lead to unwanted scrutiny, including audits. It's really just as simple as billing for the work your physician actually did, and avoiding double-dipping, says Eric Sandham, compliance manager for Central California Faculty Medical Group in Fresno, Calif.
 
Unfortunately, if the primary-care doctor or cardiologist bills for the surgical code using modifier -55 and the surgeon doesn't use modifier -54, "they'll try to take the money back from the surgeon," Cobuzzi says. It's important for the nonsurgeon to coordinate "to make sure the surgeon doesn't get blindsided."
 
As long as the nonsurgeon is seeing the patient for other conditions unrelated to the surgery as well, it's no problem to bill for E/M visits instead of the post-op care, says Stacey Elliott, coding consultant with  JR Associates in Grants Pass, Ore. "It's going to be virtually undetectable if the patient has more than one condition and is not coming in strictly for that
follow-up."
 
But if the surgeon and nonsurgeon both use the same diagnosis codes, or the nonsurgeon only bills using a V code for postsurgical follow-up, this could send up a red flag, Elliott says. If the nonsurgeon really is performing postsurgical follow-up, he or she should bill for 99024 (Postoperative follow-up 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).