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:
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 Â§Â§4822.A.3, 4822.B, and 4824.B.
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.
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