Part B Insider (Multispecialty) Coding Alert

Published on Mon Nov 03, 2003 PDF

One doctor operates, another follows up: here's how both can get paid

When one surgeon operates on a patient and then another surgeon or other physician provides all the post-operative care, you can carve up that surgery code like a turkey - just make sure everyone knows their table manners.
 
You can use three modifiers to break up the surgical package and allow more than one doctor to bill for parts of it, says Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, N.J. Modifier -54 is for surgical care only, modifier -55 covers post-op management, and modifier  -56 covers preoperative management.
 
You would bill for the surgical code with the applicable modifier or modifiers. "Those are designed to reimburse surgeons and pc docs that do parts of the surgical package," Cobuzzi says.
 
One of the doctors Cobuzzi worked with went skiing and fractured his hip in Vermont. One surgeon operated on his hip in Vermont, then he came home and another surgeon did his postoperative care. So the Vermont surgeon could bill for the pre-op and surgery, and the home-town doc could bill for the post-op care.
 
Another example is a surgeon who travels to underserved rural areas and performs surgery, then hands the patients off to local doctors. Or patients could travel from a rural area to a city to have a surgery, then return to their own doctors for follow-up care, Cobuzzi says.
 
Generally, Medicare will reimburse 10 percent of surgical costs for pre-op care, 69 percent for the surgery itself and 21 percent for post-op care, Cobuzzi says.
 
When you separate the surgery coding, you may have trouble with payers, says Rhonda Petrucillo, director of revenues and reimbursement for medical operations for Metro Health Medical Center in Cleveland. "The best hope is that you actually have documentation by the actual surgeon that supports the pre- and post-op care being provided by another outside physician."
 
It is most important to obtain an actual transfer of care, says Laureen Jandroep with A+ Medical Management & Education in Absecon, N.J. That should include a letter from the surgeon to the post-op provider saying, "Here's Patient X, please follow her." And the surgeon should mark the date of transfer on the claim form.