Corporate

February 26, 2013 - Revised: 02.27.13

Split Post-Op Care and the Global Surgery Package

Medicare reimbursement for surgical procedures is based on a 'package' of care that includes preoperative, intraoperative and postoperative care. When the package of care is split between two or more physicians or other health care practitioners, claims must be submitted according to these instructions in order for each physician to be reimbursed appropriately.

Physicians Who Furnish the Entire Global Surgery Package

Physicians who perform a surgery and furnish all of the usual pre- and postoperative work for the global package will report the appropriate surgical code only.

  • Postoperative care is generally included in the reimbursement for the surgery and is not separately payable.
  • When the global surgical fee is submitted, CPT modifiers 54 and 55 do not apply.
  • Postoperative care (Evaluation & Management (E/M) services) may be reimbursed separately if the care is not related to the surgery. Refer to instructions for CPT modifier 24 in the CGS Modifier Finder Tool by selecting the 'Tools & Site Map' on the left side of your state’s CGS web page.

Physicians in group practice

  • When different physicians in a group practice participate in the care of the patient, the group must submit the claim for the entire global package if the physicians reassign benefits to the group
  • The physician who performs the surgery must submit the service as the performing physician. The group that employs the physician must be reflected on the claim as the billing provider.
  • When the global surgical fee is submitted, CPT modifiers 54 and 55 do not apply

Physicians Who Furnish Part of a Global Surgery Package: Split Post-Op Care

When physicians provide only part of the care in the global surgery package, each physician involved in the surgical and post-operative care must identify the specific services he/she provides. Payment for the post-operative, post-discharge care is split between two or more physicians where the physicians agree on the transfer of post-operative care.

  • Surgeons who perform the major surgery and provide partial follow up care during the global period of a surgery submit the surgery with CPT modifier 54 (“surgical care only”) on one detail line
  • The second detail line must indicate the surgery date as the date of service and the same surgery code with CPT modifier 55 (“postoperative management only”)
  • The number of postoperative days must appear in the days/units field or documentation record for electronic claims. For paper claims, the number of days must appear in Item 24g (days/units field) or Item 19 of the CMS-1500 claim form.
  • When two or more physicians provide split postoperative care, the assumed/relinquished postoperative date of care must be indicated in the appropriate documentation record for electronic claims or in Item 19 of the CMS-1500 claim form for paper claims.
  • Each provider will be reimbursed based on the proportionate percentage of care. When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services, except where stated in policies (e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care, result in payment that is higher than the global allowed amount).

Example of Split Postoperative Care

Patient A has a cataract removed from her left eye on January 7, 2013, by Dr. X. The surgery took place in an ambulatory surgical center (ASC). Dr. X follows her postoperatively for the first 10 days, then transfers the remainder of her postoperative care to Dr. Y.

Surgeon: Dr. X

Date of Service CPT Code/ CPT Modifier Place of Service Quantity Electronic Documentation Field or Item 19
1/7/2013 66984-54 24 1 Blank
1/7/2013 66984-55 24 10 Care relinquished to Dr. Y on 1/17/2013

Physician to whom care was transferred to: Dr. Y

Date of Service CPT Code/ CPT Modifier Place of Service Quanity Electronic Documentation Field or Item 19
1/7/2013 66984-55 24 80 Care assumed from Dr. Y; 80 days to follow 1/18/2013

Transfer of Postoperative Care

When transfer of care occurs immediately after surgery, the physician other than the surgeon who provides the in-hospital postoperative care submits the claim using subsequent hospital care codes for the inpatient hospital care and the surgical code with CPT modifier 55 for the post-discharge care.

Other Tips

  • In all instances where postoperative care is split between the surgeon and another physician, the surgeon submits the surgery code with the CPT modifier 54.
  • Physicians who provide follow up services for minor procedures performed in emergency departments must submit the appropriate level E/M office visit code. No modifier is necessary in these situations.
  • The physician who performs the emergency room service must submit the claim for the surgical procedure without a modifier.
  • If the services of a physician other than the surgeon are required during a postoperative period for an underlying condition or medical complication, the other physician reports the appropriate evaluation and management code. No modifiers are necessary on the claim.
  • Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.

References:


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