Modifier 55 NIGHTMARE

elenipete

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Can anyone please tell me how to get a claim paid when using modifier 55?

We had a patient who came in as post operative management care after having ORIF on tibia out of state. According to Medicare guidelines you are to bill the procedure using date of procedure with modifier 55 and place of service being 11.

https://www.novitas-solutions.com/w...l-state=12ispkcopt_4&_afrLoop=71312025838984#!


we are getting denied for place of service.

I have called BCBS so many times regarding this, asking specifically if they adhere to medicare guidelines. I have sent pages and pages of documentation on this. The problem is that the hospital sent their claim to their out of state BCBS and I sent mine to our out of state BCBS and they have no record of the original claim, or so this is what the representative I spoke with told me.

Any ideas?
Frustrated with BCBS beyond my limits. I absolutely dread in having to call them..... so much so that it puts me in such a foul mood.
PLEASE HELP
 

mitchellde

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I think it is the date you are putting down that is the problem . The DOS for the visit should be the visit date in your office. then use the procedure code with the 55 modifier, the original date of the procedure I believe goes in field 15, or not at all.
 

csperoni

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The instructions on the Novitas website do state to use the date of SURGERY as the DOS.

The only item I saw on their instructions that you did not mention was in item 19/electronic equivalent = the date post-operative care began and ended along with the number of post-operative care days provided.

I also found on the CMS website these instructions:
The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.”
• Use modifier “-55” with the CPT procedure code for global periods of 10- or 90-days.
• Report the date of surgery as the date of service and indicate the date that care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.
• The receiving physician must provide at least one service before billing for any part of the postoperative care.
• This modifier is not appropriate for assistant-at-surgery services or for ASC facility fees.
Link for full info: https://www.cms.gov/Outreach-and-Ed...oducts/downloads/GloballSurgery-ICN907166.pdf

I'm not sure what CMS means by "the receiving physician must provide at least one service before billing for any part of the postoperative care." Does that mean they WANT you to first bill a new patient visit, and then the surgery code-55??
Also, are you certain the surgeon who performed the surgery billed with -54??

Honestly, I know it's not correct, and would certainly not do it for Medicare, but I might consider billing E&M for a commercial carrier who is not following the Medicare advised billing policies in this case.
 

mitchellde

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ok I get it, the rules have changed somewhat. The receiving physician must provide one post op visit before you can bill for any of the rest of the post op visits. so you perform the first one and you cannot bill for it until you have provided at least one more. Then:
"Providers need not specify on the claim that care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field/free text segment on the claim form/format. Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record."
That would be field 19 where that info must go. ALSO the physician that performed the surgery must bill their claim with the 54 modifier. If all goes correct and everyone plays their part the claim should pay.
 

sxcoder1

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As mentioned above, I also wonder if you are sure that the surgeon billed with modifier 54? I worked in ortho for several years and we often had people who had surgeries out of state and we always just billed E&M's for the follow up care. It was just too hard to ever track down how it was originally coded. Our E&M's always got paid.
 

elenipete

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billing modifier 55 to BCBS nightmare

Thank you all for all the helpful suggestions. I did the line 19, for the date we took over care, and billed a 99024 for his first post op vist with us. I am not sure how the surgeon billed. I know I have sent them corspondence with transfer of care, that they should have billed with modifier 54 and if they did not, I suggested that they submit a corrected claim. I have also sent this to BCBS- asking them to retract payment from the surgeon, making them submit a corrected claim. Still at a loss, I have asked for a claims manager everytime I call, and it is usually a call wait time of 30 minutes or more, which puts me behind in anything else I need to do.
 
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