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Surgical Fee Splitting

  1. #11
    Greeley, Colorado
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    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.
    Lisa Bledsoe, CPC, CPMA

  2. #12
    Columbia, MO
    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 ยงยง4822.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.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    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.

  4. #14
    Columbia, MO
    I think you can count on it to vary from payer to payer!

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    Medical Billing
    Quote Originally Posted by mitchellde View Post
    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.
    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 > from the OIG and here from the AMA >

    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.
    Cyndee Weston, CPC, CMC, CMRS
    American Medical Billing Association
    AMBACode Coding Software
    2015 AMBA National Medical Billing Conference

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