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Post Op pt surgery out of state-E/M

  1. #1
    Default Post Op pt surgery out of state-E/M
    Medical Coding Books

    We had a patient come to our office that is in the Post op period for open heart surgery procedure that was done OUT of State. Patient came to us for post op care- Dr. wants to bill for new pt consult. is this allowed??? Pt has never been to our group. But again is Post op. Could I add 55 modifer and still bill consult 99245? thanks

  2. #2
    Did the patient refer himself to your clinic? If so, this isn't a consult and should be coded as a new patient visit, 99201-99205. The physician who performed the surgery would have to append modifier 54 for surgical care only so the insurance carves out the "global days" that are included in the payment. Your physician should add modifier 55, postoperative management only.

  3. #3
    Patients cardiologist referred him to us. I'm just hoping the surgeon put a 54 on his services. thanks

  4. #4
    North Carolina
    I agree with AR. Sounds like a transfer of care (not a consult) for the remainder of his post op care. I would contact the originating surgeons office and have them append a modifier 54 to their claims...if they haven't already done so.

  5. #5
    yeah, it's a transfer of care even though the cardiologist referred... use your new patient codes, not a consult

  6. #6
    Milwaukee WI
    Default -54 modifier for surgeon / -55 modifier for you
    Contact the surgeon who referred the patient to you.

    The surgeon should use a -54 modifier on his/her procedure code.
    You should code the exact same procedure with the -55 modifier.

    No new patient visit. No consult. You'll get paid the "post op care" portion of the RVU for the procedure for the 90 day global period.

    F Tessa Bartels, CPC, CEMC

  7. #7
    North Carolina
    Ohh...I did forget to mention that. Thanks for the catch, Tessa.

  8. #8
    Tessa I sent you the "consult". Billing the surgical prcodeure seems impossible to me. This is an out of state Dr. and our dr has no license for that state. Provider numbers etc... Hospital info . ???

  9. #9
    Milwaukee WI
    Default This IS a consult
    Having looked at the actual documentation and understanding the scenario better, this really is a consultation.

    However ... just for education purposes ...

    Even if the procedure was done in a different state ...
    The doctor performing the procedure appends a -54 modifier to the CPT code(s).
    The doctor providing the post-op care appends a -55 modifier to the exact same CPT code(s) the surgeon used. Your place of service is office (or hospital outpatient clinic). The -55 modifier tells the insurance that ONLY post-op care is provided. You then use the 99024 post-op F/U "no-charge" for any visits in the global period.

    We have used this in orthopaedics ... child broke his leg skiing in Colorado. Fracture care provided there; he comes back here to where our ortho specialists take over his follow-up. We contact the Colorado surgeon and bill the exact same code(s) w/ -55 modifier and POS 22 (we're a hospital-based clinic). Doesn't happen every day, but we haven't had a problem with this.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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