Wiki Surgical Fee Splitting

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medicalbiller1964

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I went to a seminar approved by the AAPC, last week. The instructor brought up medical/cardiac clearance prior to surgery. She said if the surgeon requests clearance prior to surgery, the insurance company will pay the clearing physician. However, she stated that the payment would be 10-15% of the payment for the surgery and would be taken from the surgeons payment. I work for a surgeon. He says thats fee splitting and is no longer allowed. Who's right? :confused:
 
Fee splitting is when professional fees are split with a lay person (not a licensed provider) or more often can involve paying a fee for patient referrals. Fee Splitting is unethical and illegal (probably in every state).

The scenario you described is kind of like when when a patient goes on vacation and falls, has a fx of their arm and it's initially treated there. That provider bills only for the initial treatment and when the patient goes home, the provider there bills for the follow up treatment. That isn't fee splitting. Your doctor is incorrect.
 
no she was referring to using the surgical split care modifiers, 54 , 55, 56. When a surgeon requests that the PCP perform a preop eval it is to be billed using the surgical code plus the 56 modifier, this is reimbursed at 10 to 15% of the global allowable and the surgeon's reimbursement is reduced by this amount. It is not an outdated practice, and in fact is gaining in popularity. A recent Blue Cross modifier manual states they will reimburse 15% when preop is billed this way. It is the way it was designed to be done as a surgical global should be reimbursed only once, but when a surgeon bills global and the PCP bills an ov they payer is paying twice for preop when it was done by only one provider.
 
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Yes, I think we're both getting at the same thing, just saying it differently. The preop provider only bills for the preop exam but it isn't fee splitting, the surgeon is only being paid for the services he performs because the preop exam is paid to someone else. :eek:
 
Yes but that is fee splitting isn't it? LOL! That is the surgical global is being split between two different providers. The preop doc bills using the 56, and the surgeon bills using the 54, and the 55 for the post op, thereby "splitting" the fee. I am sure this is what the AAPC instructor was referring to and not to an unethical practice.
 
I thought that sounded familar! The more I reasearch other issues the more I keep running across payers requesting the use of the 56 modifer for preop. It is becomming very popular and from a cost saving perpective I think we can see why.
 
What about the pre-op clearance scenario where we used to code consults (for Medicare) and still can for private payers? I don't understand how the PCP who does a "clearance" really has anything to do with the pre-op portion of a procedure (decision and discussion of the procedure with the patient). Not being argumentative, i just don't see it that way...I welcome the information and education!! :)
 
The preop is not a consult, you cannot consult your own patient back from the surgeon. The surgeon has requested a preop clearance and it is part of the sugical process which is why the AMA created the split care modifiers. If you have been requested to provide the preop clearance then you should bill the preop portion of the surgery. The reason it ever got started as billing it as a consult was because when billed as a ov the claim failed as being part of global, so the pcp offices tried something else and found out the consult codes would bypass the edit and would pay. But this then was one hot issue with CMS and they tried to educate that this was incorrect, then based on the audit results last year they made the decision to invalidate consult codes. One of the biggest issues per the audit was the use of consult codes for preop.
As far as preop being part of surgery, it definitely is, that is the part of the global where the patient is checked to be sure that they can withstand the duration of the surgical event, it is the evaluation of the patient's medical status and the determining if additional testing is necessary such as labs and EKGs, this is what the pcp is doing AT THE REQUEST of the surgeon. SO the surgeon invites the pcp into the surgical event ant that part is extremely important to the use of the 56 modifier.
Does this make sense in any way?
 
Thanks for the feedback Debra.

What I have seen over the years are a multitude of articles stating that coding a consult for a pre-op was indeed valid, because the surgeon is asking for the PCP's opinion (and of course report back) as to whether or not the patient is medically stable for surgery. This is the first I have heard of the -56 modifier being used in this manner (how does the pre-op provider know what the actual surgical procedure will be?). If I looked back at all my consultation "data", i know I would find many articles from many sources, including CMS that would support this train of thought.

However, with all the different coding opinions out there it is hard to determine the more black and white answers in the grayer areas!

With CMS doing away with consultations, what prevents a PCP from simply coding 9921# when they do a pre-op clearance? I have not seen or heard of these being denied by CMS or any commercial payors (yet). Plus, CMS always paid the cosnults with the pre-op V code as the primary dx.

I think it is a really good topic that deserves more investigation and input form the AMA.

Thanks again Debra - as always it is a pleasure and educational experience to read and participate in posts with you.
 
I know what you mean about the ambiguity, I started researching this several years back, since then I have had many denials for ov when billed for preop and several more where the payer requested take backs later down the road. I talked with several consultants along the way and they stated that if you used the consult codes it would bypass the edit and would pay. And it will! But you have to question wheter this is correct. CMS will pay the consult but we must remember that payment is not a guarantee that we coded it correctly. I have several things I am using in some of my classes I will give you here for consideration. Just so you know I did not make this up! LOL:
Federal register
Physicians Furnishing Less Than the Full Global Package

Medicare is encouraging all providers to use appropriate modifiers when billing for services as
identified in the global surgery package. Services billed without the use of these modifiers could result in the reduction/denial of services. Split-Care is a subject that needs attention. During a recent Medicare audit, it was brought to attention how a physician was charged with an overpayment assessment, because of improper billing of surgical services.

When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed the allowance for the global package. (e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care). See MCM §§4822.A.3, 4822.B, and 4824.B.
Split-Care reimbursement.
Pre-op 10% Intra-op 80% Post-op 10%


Physician News Digest May 07
Modifier -56 is used when one physician performs the pre-operative care and another physician performs the surgery. To bill for pre-operative care without the performance of the surgery, attach a modifier -56 to the procedure code. Some insurance companies will not recognize modifier -56 and in fact, many billed services with modifier -56 will come under review. Modifier -56 can have an effect on payment of the service and may be used on Medicare claims. For an example, a patient presents to his cardiologist for his pre-operative examination and testing. The patient then travels to a cardiothoracic surgeon to have the surgery performed. The patient’s cardiologist will bill for services using modifier -56.
Alice Anne Andress, CCS-P, CCP is the Director of Physician Services at Parente Randolph, LLC.

Blue Cross Modifier Usage Guide 2010
Modifier 56 – Preoperative Management Only
Modifier 56 is reported when one physician performed the preoperative care and evaluation and another physician performed the surgical procedure. Modifier 56 is appended to the surgical code. The physician is paid a portion of the global package.
Modifiers 56 should only be appended to the surgical procedure codes.
Procedure codes with modifier 56 appended will price at 15% of the allowable charge.
Clinical Information Requirements:
Medical records are not required with the claim, but must be available upon request.
Clinical information documented in the patient’s records must support to use of this modifier.
The portion of the global days the patient was seen by the provider must be indicated in the documentation.
 
When the great great expert Heads are getting into healthy discussion like this, wow, it is an overwhelming , overflowing joy and sweet fruit for persons like us. Thank you all for this thread.
So, the preop split fare is finally 15% or 10 %? or, medical 10% and BC 15%.
We expect more like this from you all.
 
mitchellde said:
Yes but that is fee splitting isn't it? LOL! That is the surgical global is being split between two different providers. The preop doc bills using the 56, and the surgeon bills using the 54, and the 55 for the post op, thereby "splitting" the fee. I am sure this is what the AAPC instructor was referring to and not to an unethical practice.
Click to expand...

Respectfully, Fee splitting is the technical term for the practice of sharing fees among colleagues in return for being sent referrals and is prohibited. The AMA provides that payment by or to a physician solely for the referral of a patient is unethical as is the acceptance by a physician of payment of any kind, and in any form, from any source and is considered unprofessional conduct. I think that must have been what the provider thought was illegal. See OIG documentation on fee splitting here > http://oig.hhs.gov/oei/reports/oai-12-88-01412.pdf from the OIG and here from the AMA > http://virtualmentor.ama-assn.org/2009/05/hlaw1-0905.html

Being paid a portion of the global fee is different.

I do find your research and experience on billing the preop exam with modifier -56 very interesting. Thank you for sharing that information.
 
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