Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

A47790

Article

No

Co-Management of Surgical Procedures

A47790

Pennsylvania, Maryland, District of Columbia, DELAWARE

07/11/2008

08/01/2008

N/A

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This information does not take precedence over CCI edits. Please refer to CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

When applicable, physicians must indicate that their services were provided in an incentive-eligible rural or urban HPSA by using one of the following modifiers:

QB - physician providing a service in a rural HPSA; or

QU - physician providing a service in an urban HPSA

When different physicians in a group practice participate in the care of the patient and all the physicians reassign benefits to the group, the group bills for the entire global package. The physician who performs the surgery is shown as the performing physician. No modifier is necessary.

Physicians who furnish part of a global surgical package and agree to the transfer of care during the global period, the appropriate CPT modifier must be appended to the surgical procedure code:

-54 for surgical care only; or

-55 for postoperative management only.

When one physician is providing the surgical care and another is providing the post-operative management, both claims should be submitted with the date of the transfer of care in item 19 on the CMS-1500 form or the equivalent for electronic submissions.

If the physician who performed the surgery relinquishes care any time after the surgery, he/she must indicate the date of the transfer of care in item 19 of the CMS-1500 form, or equivalent for electronic submissions. In addition, he/she must code the surgical code with modifier -54.

Where a transfer of postoperative care occurs, the receiving physician must report the date the surgery was performed in item 24A of the CMS-1500 claim form or the equivalent for electronic submissions. In addition, he/she must code the surgical code with modifier –55. Additionally, the exact dates for which he/she provided post-op care management must also be reported in item 19 of the CMS-1500 claim form or the electronic equivalent.

The receiving physician may not bill for any part of the global services until he/she has provided at least one service. Once the physician who provides the post operative management has seen the patient, that physician may bill for the period beginning with the date on which he/she assumes care of the patient.

The provider responsible for postoperative care during a global surgery period should use modifier -55 for care related to the original procedure that is rendered during that period. However, modifier -24 should be added to any evaluation and management (E&M) service(s) reported during the postoperative period that is/are unrelated to the original procedure.

If portions of the global period are provided in different localities, the services should be billed to the carrier servicing each applicable payment locality (e.g., if the surgery is performed in one locality and the postoperative care is provided in another locality, the surgery is billed with modifier -54 to the carrier servicing the payment locality where the surgery was performed, and the postoperative care is billed using modifier -55 to the carrier where the postoperative care was performed). This is true whether the services were performed by the same physician/group, or by different physicians/groups.

If the transfer of care occurs immediately after surgery, the physician who provides the in-hospital postoperative care should bill using subsequent hospital care codes for the inpatient hospital care and the surgical code with the -55 modifier for the post-discharge care. The surgeon of record should report the surgery code with the -54 modifier.

Surgical Services

Refer to LCD Co-Management of Surgical Procedures for additional information.

A47790