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Confused with Modifier 55

  1. #1
    Adirondack Chapter of Professional Coders, Glens Falls, NY
    Default Confused with Modifier 55
    Medical Coding Books
    Does anyone have experience with modifier 55? I work for two doctors, and the one doctor has a well established patient that he did sugery on, and he asked the other doctor, who has never seen nor treated this patient, to see him for all of his follow up visits after surgery (he is still an inpatient at the hospital). Because the patient is still in the global from his surgery, I am wondering if there is a way to bill and get paid for this since he is being seen by a different doctor during the post-op period, however, I don't know if I would bill the E/M code with the modifier 55 or if I have to bill the same code we billed for the surgery with the modifier 55. I have seen documentation which says both, and I', confused. Please help!!!

  2. #2
    Milwaukee WI
    Default Are the doctors partners?
    First ... are both doctors in the same practice and of the same specialty?
    If the answer to that question is YES ... then the global period applies to the partner, even if s/he has never seen this patient before. For billing purposes multiple physicians of the same practice AND same specialty are considered the same doctor.

    If the answer to that question is NO ...
    The surgeon who performs the operation bills using a -54 modifier. The physician who takes over post-op care bills the exact same CPT procedure code with a -55 modifier.
    For example, let's say Ortho surgeon 1 performed open treatment of tibial fracture; but transfered post-op care to a Cardiologist because patient had some heart condition.
    Ortho surgeon bills CPT 27535-54; Cardiologist bills CPT 27535-55. (And for the second doctor - pay attention to the global period; once you're out of it, if you are still seeing the patient you go back to billing as per usual.)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Tessa -

    Do you have a reference for the two doctors being considered one for global surgery?

    Amy Crego, CPC, CPC-P, CPMA, CRC
    Vice President, Columbus, OH AAPC

    One can never consent to creep when one feels an impulse to soar. ~ Helen Keller

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