Wiki New pt E/M

[coders_rock!]

A patient was injured in another state & received surgery with a 90 day global. The pt. comes back home & comes in to see your Dr. as a new patient. Can you bill a new pt E/M & the surgery with code with modifier {55} or do you just bill the surgery code with modifier {55}?

Thanks for all your help.

 

[btadlock1]

A patient was injured in another state & received surgery with a 90 day global. The pt. comes back home & comes in to see your Dr. as a new patient. Can you bill a new pt E/M & the surgery with code with modifier {55} or do you just bill the surgery code with modifier {55}?

Thanks for all your help.

If he only saw them for surgery follow up, then just the surgery code (with the modifier for post-op care only). However, if he evaluated and treated a separate condition (Diabetes, HTN, etc.), then you can bill the new patient E/M also, with a 25 modifier. Hope that helps!

 

[coders_rock!]

Thanks for the clarification. I ended up going with the surgery with modifier [55].

 

[dballard2004]

Per CMS guidelines, there has to be a written transfer of care agreement between the surgeon and your provider in order to split the care and report modifier 55. If there is no written transfer of care agreement in this case, then your provider would only bill the E/M code.

The written transfer of care agreement is a CMS requirement, so if the payer is not Medicare here, then I would recommend you check with your payer to see what their requirments are for reporting modifier 55.

Hope this helps and this is my opinion.

 

[dballard2004]

Something else to add here.....the written transfer of care agreement is important because in order for you to bill modifier 55, the surgeon has to bill the surgery code with modifier 54.