Part B Insider (Multispecialty) Coding Alert

Published on Fri May 01, 2009 PDF

Plus: Pay attention to whether your payer is recognizing your modifiers.

You should never report services using modifiers 54 and 55 simply because of the practices financial benefit. Your physician needs to document in the medical record, prior to surgery, the reason for providing shared care, as well as the patients request for, understanding of, and agreement to this care plan.

The way these modifiers should be used is for the convenience of the patient, stresses Maggie Mac, CPC,CEMC, CHC, CMM, ICCE, manager at Pershing Yoakley & Associates, P.C. in Clearwater, Fla.

Example: A patient wants to see a physician in New York for a surgery because of that physicians expertise in the particular surgery, but the patient lives in New Jersey.

The patient does not want to travel to New York for the postoperative care.

You would employ modifiers 54 and 55, she explains.

It is decided, in advance, by both offices who is going to do what, and when the other physician is going to take over the postop care, Mac explains.

Both surgeons should indicate in their particular medical records and on their claim submissions (box # 19 on the 1500 form or in an equivalent space on the electronic medical claim) when the operating physician terminated care and when the second physician assumed postoperative care. This allows the payer to assign the proper reimbursements to each physician for their particular surgical and postoperative services.

Review your EOBs: Another problem is with the insurance companies that do not recognize these modifiers and pay the full allowed amount, says Jennifer Vanderhorst, CPC, coder for Michigan Urological Clinic in Grand Rapids. I have had the personal experience of getting paid $1,000 for a postop visit, when the modifier was appended correctly.

If the payer overpays you, make sure you repay the overpayment.

Otherwise, you could face a review and payment issues later on when the payer realizes what occurred.

Want to learn more? You can find out about modifiers 54 and 55, plus all of the other modifiers that are important to your Part B Medicare coding, by searching our article archives online -- free for subscribers. Just visit www.coding411.com to register and get access to online archives, code lookup resources, and coding discussion groups.