Understanding Split Billing for Post-Op Care

Reimbursement for most surgical procedures is based on a 'package' of care that includes three components: preoperative care, intraoperative (surgical) care, and postoperative care/ post-op care. CMS has assigned a specific reimbursement percentage for each of these components. 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. 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. 

When the package of care is split between two or more physicians, each physician involved in the surgical and post-operative care must identify the specific services he/she provides. Each provider will be reimbursed based on the proportionate percentage of care. The sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services.

Guidelines on Splitting 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 modifier 54 i.e., surgical care only.
• The second line must indicate the surgery date as the date of service and the same surgery code with modifier 55 i.e., postoperative management only.
• The number of postoperative days must appear in the days/units field or documentation record for electronic claims (for paper claims, in Item 24g (days/units field) or Item 19 of the CMS-1500 claim form). The assumed/relinquished postoperative date of care must be indicated.
• In all instances where postoperative care is split between the surgeon and another physician, the surgeon submits the surgery code with the 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.

Transfer of Post-Op Care

When the 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.

Example of Split Post-Op Care

Physician A performs a hysterectomy (58150) on 04/15/2019 in the hospital. The procedure has a 90-day global period. The patient was in the hospital for 8 days until 04/23/2095 during which time physician A administered post-operative care. On 04/24/2019, physician B took over the post-operative care, which was administered in the office.

	Physician A	Physician A	Physician B
Date of Service	04-15-2019	04-15-2019	04-15-2019
CPT Code	58150	58150	58150
Modifier	54	55	55
Place of Service	21	21	11
Quantity	1	8	1
Documentation Field (Item 19)	blank	Post Op Care performed 04/16/15 to 04/23/15 i.e., 8 days	Post Op Care assumed 04/24/15 to 07/14/2015 i.e., 82 days

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 Furnishing the Entire Global Surgery Package

Physicians who perform 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 (E/M services) may be reimbursed separately if the care is not related to the surgery. In this case, you can refer modifier 24.

About Medical Billers and Coders

We are catering to more than 40 specialties, Medical Billers and Coders (MBC) is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. The main goal of our organization is to assist physicians looking for billers and coders.

---

Published By - Medical Billers and Coders
Published Date - Dec-28-2020 Back