Wiki post op (fracture) care

[Lisa Bledsoe]

We have submitted a claim to Medicare for 25605-55 for a PA in our practice (under her NPI). The patient had his initial fracture treatment out of town, and upon returning home is following up at our practice. Medicare is denying this claim as not covered when performed by this provider. Does anyone have any explanation as to why a PA cannot provide the post-op (fracture) management for this? I'd like to appeal this at a higher level but would really appreciate some input from my peers.
TIA

 

[mitchellde]

Did you put a transfer of care note in Box 19? and do you have a chart notation showing the transfer from the treating physician? You will need that to appeal. Otherwise unless your PA is not credentialed with Medicare I am out of ideas.

 

[Lisa Bledsoe]

Thanks Debra. She is credentialed with Medicare. The chart note does state that the closed reduction was done by another physician in a different facility. I don't think our claim had any note about transfer of care in box 19. So other than box 19 it seems I should have enough to appeal with, would you agree? Thanks for your help!

 

[mitchellde]

I agree with the appeal as long as you have some documentation where the original physician transferred the postop to you.

 

[chrislyn1977]

I always thought that the original treating provider had to bill using the same CPT code with a 54 and 56 modifer. That way the provider handling the post op care could bill with modifier 55.

If the original treating provider billed the fracture care code without the appropriate modifiers then they have been paid the entire global fee (pre, surgical, and post), which would be incorrect and would prevent you from receiving your proper payment.

In this business we have to rely on the original treating provider to bill correctly.

Just a thought.

Christy Brown, CPC
Appalachian Orthopedic Associates PC

 

[mitchellde]

good point! I had not thought of that but you are right if they billed global it is an issue. The only way around that is to appeal and that is why the transfer of care documentation is critical.