Friday, August 20, 2010

Surgical care Modifier - 54

Modifier 54 Fact Sheet

Definition:

• Modifier 54 indicates that the surgeon is billing the surgical care only.

Appropriate Usage:

• When all or part of the postoperative care is relinquished to a physician who is not a member of the same group
• Appended to the procedure code that describes the surgical procedure performed that has a 10 or 90-day postoperative period.

Inappropriate Usage:

• Appending modifier 54 to a surgical procedure without a global period or procedure other than 010 or 090 global days

• When the covering physician (i.e. locum tenens) belongs to the same group as the surgeon and the surgeon provided most of the postoperative care

• Appending to an E/M procedure code

• Appending to an assistant at surgery service

The Medicare Physicians Fee Schedule Database (MPFSDB) indicates the reimbursement percentages for each portion of the global period of major and minor surgical procedures.

Most major (90-day global period) surgeries reimburse 10% of the physician fee schedule amount for the pre-op, 70% for the intra-op and 20% for the post-op period.

Most minor (10-day global period) surgeries reimburse 10% of the physician fee schedule amount for the pre-op, 80% for the intra-op and 10% for the post-op period.

For example, Doctor A performs the pre-op visit and the major surgery; therefore, he receives 10% of the physician fee schedule amount for the pre-op period and 70% for the intra-op period when billing with modifier 54.Doctor B covers the patient for the entire post-op period; therefore, he
receives 20% of the physician fee schedule amount when billing with modifier 55.

Using Modifiers “-54” and “-55” on Global Surgery period

Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier:

• Surgical care only (modifier “-54”)

• Post-operative management only (modifier “-55”)

The physician must use the same CPT code for global surgery services billed with modifiers “-54” or “-55.” The same date of service and surgical procedure code should be reported on the bill for the surgical care only and post-operative care only. The date of service is the date the surgical procedure was furnished.

Modifier “-54” indicates that the surgeon is relinquishing all or part of the post-operative care to a physician.

• Modifier “-54” does not apply to assistant-at-surgery services.
• Modifier “-54” does not apply to an Ambulatory Surgical Center (ASC’s) facility fees.

The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.”

• Use modifier “-55” with the CPT procedure code for global periods of 10- or 90-days.

• Report the date of surgery as the date of service and indicate the date that care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.

• The receiving physician must provide at least one service before billing for any part of the postoperative care.

• This modifier is not appropriate for assistant-at-surgery services or for ASC facility fees.


Exceptions to the Use of Modifiers “-54” and “-55”


Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate Evaluation and Management (E/M) code. No modifiers are necessary on the claim.

Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier.

If the services of a physician, other than the surgeon, are required during a post-operative period for an underlying condition or medical complication, the other physician reports the appropriate E/M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient,,


Modifier-54: Surgical Care Only

This modifier is used by the surgeon and when another physician provides preoperative and/or postoperative care. This modifier is appended to the surgical procedure code. Modifier-55: Postoperative Management Only

This modifier is used by the physician who provides postoperative care when another physician has done the surgical procedure. This modifier is appended to the surgical procedure code.
The physician receiving the patient must be licensed to manage all aspects of the postoperative care, including the ability to diagnose potential complications that would require another operation.

Documentation Requirements


1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
3. The submitted medical record should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
4. The medical record documentation must support the medical necessity of the services as directed in this policy.
5. The surgeon should write his/her usual operative note. The physician providing postoperative care should document appropriate follow-up care notes.
6. Transfer of Care must be in writing and dated. The record must indicate the exact date on which post-operative care is assumed by the co-managing physician.
7. Additionally, the medical record must indicate that the patient was appropriately informed of the medical and/or logistic advisability of transfer of care along with any risks or benefits of this arrangement, and that the patient gave consent to this arrangement prior to its inception.
8. The documentation that the patient was properly informed as described above, must be made available upon request.

REIMBURSEMENT GUIDELINES:

The Plan will reimburse approved service lines reporting modifier 54 at 60% of the allowance.
The Plan will reimburse approved service lines reporting modifier 55 at 20% of the allowance.



UHC guidelines - usage of Modifiers 54 and 55

Using Modifiers “-54” and “-55”


Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier:

* Surgical care only (modifier “-54”); or
* Post-operative management only (modifier “-55”).

For global surgery services billed with modifiers “-54” or “-55,” the same CPT code must be billed. The same date of service and surgical procedure code should be reported on the bill for the surgical care only and postoperative care only. The date of service is the date the surgical procedure was furnished.

Modifier “-54” indicates that the surgeon is relinquishing all or part of the post-operative care to a physician.
* Modifier “-54” does not apply to assistant at surgery services.
* Modifier “-54” does not apply to an ASC’s facility fees.

The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.”
* Use modifier “-55” with the CPT code for global periods of 10 or 90 days.
* Report the date of surgery as the date of service and indicate the date care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in beneficiary’s medical record.
* The receiving physician must provide at least one service before billing for any part of the post-operative care.
* This modifier is not appropriate for assistant at surgery services or for ASC’s facility fees. Exceptions to the Use of Modifiers “-54” and “-55”

Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by use of the appropriate level Evaluation and Management (E/M) code. No modifiers are necessary on the claim. Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier. If the services of a physician other than the surgeon are required during a post-operative period for an underlying condition or medical complication, the other physician reports the appropriate level E/M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient. E/M Service Resulting in the Initial Decision to Perform Surgery E/M services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global  surgery payment for the major surgery and, therefore, may be billed and paid separately.

In addition to the E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery. The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. Carriers/MACs may not pay for an E/M service billed with the modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10 day global surgical period.

Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure Modifier “-25” (Significant, separately identifiable E/M service by the same physician on the same day of the procedure), indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service.

* Use modifier “-25” with the appropriate level of E/M service.
* Use modifiers “-24” (Unrelated E/M service by the same physician during a post-operative period) and “- 25” when a significant, separately identifiable E/M service on the day of a procedure falls within the postoperative period of another unrelated, procedure.

Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Both the medically-necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.


Critical care billing Modifier usage of 54


Critical care services furnished during a global surgical period for a seriously injured or burned patient are not considered related to a surgical procedure and may be paid separately under the following circumstances. Preoperative and post-operative critical care may be paid in addition to a global fee if:

* The patient is critically ill and requires the constant attendance of the physician; and

* The critical care is above and beyond, and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed. Such patients are potentially unstable or have conditions that could pose a significant threat to life or risk of prolonged impairment. In order for these services to be paid, two reporting requirements must be met:

* CPT codes 99291/99292 and modifier “-25” for pre-operative care or “-24” for post-operative care must be used; and

* Documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted. An ICD-10 code for a disease or separate injury which clearly indicates that the critical care was unrelated to the surgery is acceptable documentation. Care Provided in Different Payment Localities

If portions of care of the global surgery package are provided in different payment localities, the services should be billed to the contractor servicing each applicable payment locality. For example, if the surgery is performed in one state and the post-operative care is provided in another state, the surgery is billed with modifier “-54” (Surgical care only) to the contractor servicing the payment locality where the surgery was furnished. The post-operative care is billed with modifier “-55” (Post-operative management only) to the contractor servicing the payment locality where the post-operative care was performed. This is true whether the services were performed by the same physician/ group or different physicians/groups.




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