post operative visits/when surgeon did not perform the surgery

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165
Location
Dickson, TN
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I need some help with an issue that is coming up in our practice. The hospital where our general surgeons perform services has employed two surgeons who will perform surgery and then transfer care for the post operative period to your general surgeons. How should we be billing this post operative services? The hospital is not billing the surgery service provided by their surgeon, so if we use the procedure code with a 55 modifier it is likely not going to get paid as the procedure code will never be submitted with a 54 modifier. Are we allowed to bill a Regular E/M code or should we have a contract with the hospital to cover these cases?

any help is greatly appreciated.
Thanks
 

Kiana

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94
Location
Tucson
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This sounds like a Global fee/split care:
Per Medicare A surgeion who does not provide follow-up care would use modifier -54 (surgical care only). The doctor who provides pos-operative follow-up care should use modifier -55 (post-operative management only).

You can get credit for giving post-op care starting from the date of transfer even if you haven't seen the patient yet. But you can't file a claim for your reimbursement until after you've provided a service [CMS 100-4, 12 40.2 (A)
(3)].

Note: Before you bill for split care, keep the following exceptions in mind:
  • If there is not an official transfer of care, the second doctor may bill occasional post-discharge services with the appropriate E/M code. You don't need a modifier for such claims.
  • If the transfer of care occurs immediately after surgery, the second physician bills using subsequent hospital care codes for the inpatient hospital care and the surgical code with modifier -55 for the post discharge care. The surgeion bills the surgery code with modifier -54.
  • If the serives of a physician other than the surgeon are required during a post-operative period for an underlying condition or medical complication, the second doctor should report the appropriate E/M code. You don't need a modifier. Example: A cardiologist who manages underlyin cardiovascular conditions of a patient.

    Hope it helps. :)
 
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