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Modifier 54, 55, & 56 questions

  1. #1
    Default Modifier 54, 55, & 56 questions
    Medical Coding Books
    HELP!

    I have a question about modifiers 54, 55 & 56. I work in an ortho office and our office will have a new physician joining us. He is currently doing surgery and taking call for the local hospital. He will be seeing patients in our office in follow up of surgeries he did at the hospital. He will be an employee of the hospital for the surgery and an employee of our office for the follow ups.

    My managers (neither of which have ANY credentials) have instructed me that when I bill for the physician services in our office that I will need to use the 55 modifier (postoperative management only) for his follow up visits on patients he sees in our office. They have told me that this is ok because the hospital will be billing his charges for surgery with a 54 (surgical care only). Supposedly they have called Medicare and were told this was "fine". I have asked to see this in writing, but have not seen anything yet.

    If you read the descriptions on these modifiers, it says "ONE" physician performs the surgery and "ANOTHER" physician performs the follow up. It just does not seem right to me.

    I am going to need reference material to help me prove my point if I am correct.

    Thanks in advance for your help!
    Chris Lee

  2. #2
    Location
    ENGLEWOOD/DENVER
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    Default
    wow thats interesting..I'll bet the way that he gets around that is because of the two different tax id's. I will be interested to see if any one else does this or has encountered this.

    My ortho guys see patients at the ER/hospital and they are billed under our "trauma service" tax id. When they come to our office (different tax id) we treat them as post op.

    Soooo if you find documentation on this or anyone else has input..I'm interested in seeing it too!

  3. #3
    Default -54, -55, -56
    the only proof I can see is the CPT book itself....show your mgmt team the definitions of modifiers 54, 55, 56. The main factor is 'the physician is the same' and not 'the facility is different where he/she sees the patients'....hope this helps

    Quote Originally Posted by cleecpc View Post
    HELP!

    I have a question about modifiers 54, 55 & 56. I work in an ortho office and our office will have a new physician joining us. He is currently doing surgery and taking call for the local hospital. He will be seeing patients in our office in follow up of surgeries he did at the hospital. He will be an employee of the hospital for the surgery and an employee of our office for the follow ups.

    My managers (neither of which have ANY credentials) have instructed me that when I bill for the physician services in our office that I will need to use the 55 modifier (postoperative management only) for his follow up visits on patients he sees in our office. They have told me that this is ok because the hospital will be billing his charges for surgery with a 54 (surgical care only). Supposedly they have called Medicare and were told this was "fine". I have asked to see this in writing, but have not seen anything yet.

    If you read the descriptions on these modifiers, it says "ONE" physician performs the surgery and "ANOTHER" physician performs the follow up. It just does not seem right to me.

    I am going to need reference material to help me prove my point if I am correct.

    Thanks in advance for your help!
    Chris Lee
    Rachele Porter, AS, CPC, CPC-H, CEDC
    no weapons formed against me shall prosper

  4. Default Modifier 54, 55, 56
    If it doesn't seem right, then its not.

    Same physician-post op.

  5. #5
    Default
    I think is ok this way, because reflects who is getting paid for what.
    Think about, he is not trying to get paid twice. (neither the doc or the hospital)
    The surgery gets divided in pieces and each of them (hospital collects on behalf of the MD and pays the MD and MD for the expenses occurred at his office for the follow up visits) . I would see a problem only if the hospital would be billing without modifier and it would be collecting money for the follow up that would not provide or the doctor that would try to collect money when the facility pays for his services.

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