Wiki Bcbs billing -assumed/relinquished care

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lizzy062202

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Has anyone billed bcbs (fep) for assumed & relinquised care -- claim was submitted as 66984 55 rt & 66984 54 rt -- bcbs paid for mod 54. I have been trying since june to get the modifier 55 paid. All i keep hearing is that they will resubmit the claim. It is now december and they claim has not been paid.
Does anyone have any input?
 
Bcbs

I did submitt on the same claim. One of the BCBS reps I spoke with told me to send a corrected claim with both lines on it. Was that my first mistake? I would imagine if I sent the claims again they would be denied as duplicates. i had sent the corrected claim because they had denied the orginial claim as a duplicate because of the RT modifier that was listed on both lines .
 
If you performed the surgery as well as the post op you would not bill in this fashion. you would bill the surgery with no modifier. If your provider is performing the surgery only then you bill the surgery with the 54 modifier only. If your physician is providing only the post operative care you will use a V code for post op for the diagnosis and the surgical code with the 55 only. I can think of no scenario that will require you to bill the surgical procedure and the post op visits on the same claim as 2 lines.
 
You say care was relinquished- are you billing for the surgeon or the post-op provider? If you're billing for the surgeon, did s/he perform a portion of the post-op period and then relinquish care to another provider for the remainder? That's the only time I can think of that you would split the claim into operative and post-operative on the same claim. What units are you using for the -55 line?

As far as duplicate denials- I know I get that a lot with BCBS in error. Are you dropping to paper or resubmitting electonically? I usually drop to paper and write CORRECTED CLAIM in letters of fire across the top. Not that they still don't deny as a duplicate on occasion.
 
But even if your provider performed the surgery and only part of the post op you would not bill it on the same claim since the surgery and the post care are not performed on the same day.
 
Interesting- I work for an optometrist practice right now but most ophthalmology practices I have dealt with have billed on the same day because a) the date of surgery is used for the post-op care as well as the surgery itself and b) the relinquished care dates are usually established up front. Additionally, the claim is billed even if the post-op period hasn't been completed. NC Medicaid is the only one I've run across that requires the post-op period to have passed before submitting a claim for the post-op care.

I would think with BCBS if you billed 66985-54 and 66985-55 on separate claims but with the same date of service, that would cause duplicate denial problems, although I haven't done it so I'm not sure. I'll be interested to see how this pans out. The question still remains whether the surgeon performed the entire post-op period.
 
The day of surgery includes any service related to the surgery on that day. You would never bill the post op on the day of surgery. once you bill the surgery with the 54 that is for services on that day. The 55 modifier is for the first post day thu the end of the global. I have billed a lot of ophthalmology and never did we bill with the 54 and the 55 on the same day. The provider saw the patient in recovery and the patient returned to the regular eye doctor for the next visit.
 
I agree that that day of surgery is not considered post-op and if the only care the surgeon provided was on the day of surgery, you would just bill with the -54 and be done.. But, if the post-op period itself is split between surgeon and regular doctor, this is what Medicare instructs. Per North Carolina's MAC website (Palmetto GBA): http://goo.gl/9GMuL

Surgeon: Dr. X

Date of Service CPT Code / CPT Modifier Place of Service Quantity Item 19
1/07/2012 66984-54 24 1 Blank
1/07/2012 66984-55 24 '10' "Care relinquished to Dr. Y on 1/17/2012"


Physician to whom care was transferred to: Dr. Y

Date of Service CPT Code / CPT Modifier Place of Service Quantity Item 19
1/07/2012 66984-55 24 80 "Care assumed from Dr. X; 80 days to follow 1/18/2012"


This of course all depends on if, when, and how the post op care is split, but is one example of how you could potentially be required to bill both the surgery and the post-op care on the same day.

I hope we hear back from Lizzy; it'll be interesting to know the details. Until then this is all an interesting theoretical exercise. :)
 
they are not showing doctor x as being the same claim. These are two separate claims one for the date of the surgery that has already been submitted, the second line is the next claim to indicate that doctor x provided the first 10 days of post op and then transferred the care. You could not submit this as one claim as you would not for sure know ahead of time how may postop days dr. x would have until they were done. It is misleading in the example but read it closely.
 
I'm sorry if I'm posting this more than once; my computer's acting weird (at least that's what I'll blame it on!)

Going back to the Medicare website and reading it again, this is what I found:

"Surgeons who perform the major surgery and provide partial follow up care during the global period of a surgery submit the surgery with CPT modifier 54 (Surgical care only) on one detail line
The second detail line must indicate the surgery date as the date of service and the same surgery code with CPT modifier 55 (Postoperative management only) "

To me that still sounds like multiple detail lines on one claim. What am I missing? Also, lizzy appears to be billing after the fact in this case which means she knows what number of days to bill. In my experience, transfer of care is often scheduled in advance.
 
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