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Modifier 54 & 55

  1. Cool Modifier 54 & 55
    Medical Coding Books
    I also posted this question under E&M but decided maybe it should fall here as well, as perhaps modifiers 54/55 would fall into place:

    Hello all...

    I am causing myself some confusion and cannot find a straight answer on Medicare's website regarding the global period. My question is, does only the Physician who performed the surgery fall under the global guidelines or does his group as a whole? If we have another provider in our group see a patient during the 10 day global period for a follow up, say to renew a prescription unrelated to the surgery, is that still considered an E&M in the global period? Same for a patient who has just had an intrathecal pump implanted....if they are in the trial period, have come in within the 10 day global period and have the pump refilled or reprogrammed by another physician in the practice, can we bill, or is it considered global? I am aware of the 24 modifier, but that is for the same physician who performed the surgery...so in this case it would not apply. Should we be appending either of these modifiers to our CPT codes?

    Any input would be greatly appreciated....

    Thanks much!!

  2. #2
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    Columbia, MO
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    Global will apply to all the physicians in the same practice, I have observed some payers apply it to physician in different practices when they see a patient that is under a different physician's global.
    Also 54 and 55 are modifers to applied to procedure codes and never E&M codes.

    Debra A. Mitchell, MSPH, CPC-H

  3. Question
    Quote Originally Posted by mitchellde View Post
    Global will apply to all the physicians in the same practice, I have observed some payers apply it to physician in different practices when they see a patient that is under a different physician's global.
    Also 54 and 55 are modifers to applied to procedure codes and never E&M codes.
    Since we are in the same practice, would we need to append a 24 modifier if we do an E&M for an unrelated reason, even though a different physician in the same group? I realize the 54/55 would not apply at all. Does it need to state in the note that the visit was "Not related to the surgery" to support a 24 modifier if used? Thanks as I am confusing myself....
    Last edited by g.fairchild; 03-31-2010 at 10:25 AM.

  4. #4
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    Yes you need the note and yes you would use the 24 modifier.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    Jacksonville, FL River City Chapter
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    The global package created by one doctor applies to other doctors of the same group AND specialty, not to all in the group practice.

    So if the patient needs to be seen by someone else in the group that is of a DIFFERENT specialty than the surgeon, a visit can be billed and no modifier is necessary.

    Seth Canterbury, CPC, ACS-EM

  6. Default
    Quote Originally Posted by SCanterbury View Post
    The global package created by one doctor applies to other doctors of the same group AND specialty, not to all in the group practice.

    So if the patient needs to be seen by someone else in the group that is of a DIFFERENT specialty than the surgeon, a visit can be billed and no modifier is necessary.

    Seth Canterbury, CPC, ACS-EM
    So if we have a family practioner in with our specialists, and the patient sees her, we can bill the visit? (Even though she is credentialed under the same tax ID)...thanks.

  7. #7
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    Jacksonville, FL River City Chapter
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    Yes, as long as the FP is not stepping in on behalf of the surgeon to perform a routine post-op visit that has already been compensated to the surgeon inside the surgeon's global package fee. They cannot be paid separately for a service that has already been paid to someone else.

    If the surgeon is wanting the FP to do all or some portion of the post-op monitoring on his/her behalf, that is where the 54/55/56 comes in. If the FP is just evaluating a distinct problem that has nothing to do with the surgery, they can bill it with no modifier.

    All providers in the same group AND specialty are considered to be the "same" provider for billing purposes, so a surgeon's global package only extends to other providers in the same group AND specialty. So even if the providers are pooled into one group NPI and one tax id, the FP should still have a different specialty code on file with the payer than the specialist that performed the surgery, and this will hopefully prevent a denial.

    Seth
    Last edited by SCanterbury; 04-14-2010 at 03:06 PM.

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