When I was in training, co-management was not routinely performed by most of my attendings. Subsequently, I received little to no information about how to do it. After a lot of research and some trial and error, I put together a little guide on the nuts and bolts of co-management. We'll use a co-managed right eye cataract surgery billed to Medicare as an example. Note: not all commercial payers recognize the below modifiers.
There is a substantial amount of information on the ethics and guidelines of co-management of ophthalmic post-operative care out there. In fact, the American Academy of Ophthalmology has published guidelines about this very topic. This is not a post about the ethics of co-management or guidelines for when/why to co-manage any particular patient. I'm also not going to spend time reviewing the various legalities involved in co-managed care. In this post, we're going to focus exclusively on the coding mechanics on how to properly code and bill for co-managed surgeries.
General notes:
Post-operative care comprises 20% of the surgical reimbursement. You are then reimbursed for the percentage of post-operative care you provide. So if you see the patient for 30 of the 90 day global period for post-operative care, you receive 33% (30/90=33%) of that 20% of the reimbursement dedicated to post-operative care.
The total paid (to the surgeon and co-managing doctor) by CMS will not exceed the global reimbursement for the procedure.
If you have a co-managing doctor in your practice, you can't separate the claim into intra-operative and post-operative care. You have to only bill for the global reimbursement.
A written co-management agreement that the patient signs and that indicates agreement to the transfer of care as well as the transfer of care date must be kept in the medical record.
How to bill the surgery (-54)
When you expect to co-manage the post-operative care of a particular patient, you must append the -54 modifier to your claim for the surgery you performed. This modifier indicates that you are to be paid only for the pre-operative and intra-operative services you performed. Typically, this results in a 20% reduction in reimbursement.
How to code it:
On one line: list CPT -54 (e.g. 66984 -54 -RT)
How to bill the post-operative care (-55)
In order to be adequately compensated for your services you must append the -55 modifier and indicate the amount of time the patient was under your care post-operatively on the claim form.
How to code it:
On one line: list CPT -54
On the next list: list CPT -55 and the number of post-operative days the patient was under your care
On line 19, indicate the dates that the patient was under your care
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