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Old 10-05-2010, 11:01 AM
amyrepp amyrepp is offline
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Default Billing 55 modifier

We recently went to a coding seminar and I may have misunderstood how to use this modifier. Do you use this modifier on the E/M code or do you obtain the surgical code and use that modifier? How do you obtain the surgical code if the surgery is done out of the area? We saw the patient for a follow up on an appendectomy.
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Old 10-05-2010, 12:24 PM
Lesainc Lesainc is offline
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To use a 55 mod, you need to obtain the surgical code and submit that with the 55 on it. This signifies that your physician did all the post op care usually provided by the operating surgeon.

It decreases the pay of the operating surgeon also. (If I remember correctly it is about 17%) So you need to notifiy the operating surgeon. I also believe it has to be documented in writing from the original surgeon requesting transfer of care.

This is NOT a recent article, but I couldn't find anything more recent that was different.

Modifier -55 is used when one physician does the surgery and another physician provides post-operative care. To bill for post-operative care without performance of the surgery, attach a modifier -55 to the procedure code. Post-operative care begins the day after the surgery. If it becomes necessary for the surgeon to address a problem during the post-operative period, it can be billed separately if the service contains a diagnosis which is separate from the original procedure.

Management of patient-controlled medications are included in the surgeon’s payment for the surgery. Pain management by a continuous epidural is considered billable and would be billed using CPT code 62319 on the first day. This includes the catheter and injection of the medication. Subsequent daily management of the epidural can be billed using CPT code 01996. Both codes cannot be billed on the same day.

Any visit performed by the surgeon, which occurs one day prior to the surgery, is considered to be included. For example, when a patient undergoes a cardiac procedure performed by a cardiothoracic surgeon and then the follow-up care is rendered by the patient’s cardiologist, Modifier -55 would be added to the codes submitted by the patient’s cardiologist. Modifier -55 can have an effect on payment of the service and may be used on Medicare claims.
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Old 10-05-2010, 07:31 PM
amyrepp amyrepp is offline
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Thanks for the reply. I'm just afraid that if we just bill an e/m code than it will be denied because of global.
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Old 10-06-2010, 08:46 AM
Lisa Bledsoe Lisa Bledsoe is offline
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Mod -55 is a royal pain, especially with medicare.
1 - you must have a documented release of care from the operating surgeon (in his/her record as well as yours) for the patient.
2 - you have to enter the dates in which you will be following the patient on the claim. You have to calculate the global period, so if the patient had surgery on 1/1/10 and you started post op on 1/5/10 you enter 1/5/10 - 4/2/10 on the line item.
3 - you have to enter the number of days you will be responsible for post-op care in the units field. So if the patient has surgery on 1/1/10 and you see him/her for post op on 1/5/10 you have to enter 85 for units. BUT be careful not to let your PMS multiply by 85!! Your fee still has to be only the post op percentage of the global!
Global calculator link: http://www.medicarenhic.com/provider...al_period.html
Most MAC's have a calculator on their website, but I got this one off of the forum.
Lisa Bledsoe, CPC, CPMA
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