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Modifier 55-please help me

  1. #1
    Default Modifier 55-please help me
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    Can someone please help me with modifier 55? The following is a note from the clinic that we bill for and we have conflicting opinions on it. They are a family practice clinic. They originally coded a 99232 but then changed it to 99221 - 55 which conflicts with her note. Any opinions?

    Pt admitted to OBS via ER on 12/19/11, then to IP on 12/20/11. Pt had surgery on 12/20/11 via the surgeon. UWFM was asked to manage the patient BP per the surgeon, this visit would not be the patient's initial IP visit, it would be a subsequent IP visit. Since the patients previous IP visits would be covered under the surgical global fee, added 55 modifier to let the insurance company know we are following “postoperative management only”.

  2. #2
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    Quote Originally Posted by cwoske View Post
    Can someone please help me with modifier 55? The following is a note from the clinic that we bill for and we have conflicting opinions on it. They are a family practice clinic. They originally coded a 99232 but then changed it to 99221 - 55 which conflicts with her note. Any opinions?

    Pt admitted to OBS via ER on 12/19/11, then to IP on 12/20/11. Pt had surgery on 12/20/11 via the surgeon. UWFM was asked to manage the patient BP per the surgeon, this visit would not be the patient's initial IP visit, it would be a subsequent IP visit. Since the patients previous IP visits would be covered under the surgical global fee, added 55 modifier to let the insurance company know we are following “postoperative management only”.
    Need a bit more info. Is the surgeon part of UWFM, or are the surgeon and the physician billing this service of the same group/same specialty? If not, then this visit for BP management shouldn't be bundled into the surgical package.
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

  3. #3
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    No, the surgeon is with cardiology and UWFM is family practice. Part of our discussion is if we can bill an initial inpatient visit for the first day that our doctor saw the patient even though he had been admitted the day before. And do we need the 55 modifier to show that we are only providing post op care?

  4. #4
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    also, not sure about the payor's requirements, but from what I've learned postop care should actually be billed by using the surgery code along with the -55 modifier, that way they can calculate a percentage of the surgery fee (i.e., medicare pays I believe 20% of whatever the fee is for the surgery). But I would go by whatever the payor says as far as how to bill for postop.

  5. #5
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    Baton Rouge
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    Of course it's hard to say for sure without seeing all the documention, but from what you've described, my opinion is that it sounds like your physician was called in to manage the patient's BP, which would be consult services (using 99221-99223 if Medicare or 99251-99255 if commercial). The "typical post-op care" is for the surgeon and his colleagues...to follow the condition that led to surgery, check incision, etc., not to manage other conditions, even though they happen to occur in the post-op period.

    However, if your physician truely is following the patient for post-op care (which should have been requested by the surgeon), your physician should use the same surgical codes that were billed by the surgeon, and append modifier 55 to those, not to E/M codes.

    Hope this makes sense!
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

  6. #6
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    That actually confirmed what we thought. Thanks!

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