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Surgical Fee Splitting

  1. Default Surgical Fee Splitting
    Medical Coding Books
    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?

  2. Default
    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.
    Cyndee Weston, CPC, CMC, CMRS
    American Medical Billing Association
    www.ambanet.net/AMBA.htm
    AMBACode Coding Software
    http://www.ambacode.net
    2015 AMBA National Medical Billing Conference
    http://www.ambanet.net/2015.htm

  3. Default
    Thank you, this helps alot.

  4. #4
    Location
    Columbia, MO
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    Default
    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 It is not an outdated practice, and in fact is gaining in popularity.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.
    Last edited by mitchellde; 08-25-2010 at 10:35 PM.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    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.
    Cyndee Weston, CPC, CMC, CMRS
    American Medical Billing Association
    www.ambanet.net/AMBA.htm
    AMBACode Coding Software
    http://www.ambacode.net
    2015 AMBA National Medical Billing Conference
    http://www.ambanet.net/2015.htm

  6. #6
    Location
    Columbia, MO
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    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.

    Debra A. Mitchell, MSPH, CPC-H

  7. Default
    Hey Debra- You were my instructor, in the Detroit, on August, 19th.

  8. #8
    Location
    Columbia, MO
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    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.

    Debra A. Mitchell, MSPH, CPC-H

  9. #9
    Location
    Greeley, Colorado
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    Question
    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!!
    Lisa Bledsoe, CPC, CPMA

  10. #10
    Location
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    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?

    Debra A. Mitchell, MSPH, CPC-H

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