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Medicare billing for Cataract Post-Op Co-Management

Co-management compliance is tracking down by the U.S. Department of Health and Human Services OIG (Office of Inspector General).

You should manage the patient’s transfer of care correctly as well as it must be medically acceptable (determination is made by the surgeon and the patient).

Transfer of care is defined as a transfer of responsibility for a patient’s care from one qualified healthcare provider operating within his/her scope of practice to another who also operates within his/her scope of practice.

Now, let’s look at Co-Management and various scenarios where it is applied:

In the postoperative care relationship between an ophthalmologist/cataract surgeon and a non-operating provider (e.g., an optometrist) for shared responsibility is called as Co-management.

Various scenarios where Co-Management is appropriate:

  • The patient is unable to return to the surgeon for follow-up
  • Patient preference or the patient experiences another illness or complication that requires intervention by another provider
  • The surgeon is unavailable for care

Medicare billing for Cataract Co-Management

You be sure to use the correct modifier; when you co-manage a cataract surgical procedure that was performed by a surgeon. Your co-management claim will be denied if the surgeon has not filed their claim, or if they filed without using the correct modifier indicating surgical care only. Moreover, to avoid delayed payments good communication with the surgeon’s office should be maintained.

The surgeon submits a claim for the procedure citing the appropriate CPT code and co-management modifier (-54) on the claim form. This modifier is required to identify the surgical procedure in a co-management scenario.

Now, let’s look at various type of care provided and its modifier:

Surgical care only- (-54)

Post-operative care- (-55)

Once the co-managing provider has provided postoperative care, he or she submits a claim form citing the appropriate CPT code and co-management modifier (-55), which indicates post-operative management only, as well as the date he or she assumed the patient’s postoperative care.

Medicare Reimbursement for Post-Operative Services

The total post-operative care percentage for ophthalmic procedures has been set at 20% of the surgical fee allowance.

In cases where more than one provider furnishes post-operative services, the payment will be divided between the providers based on the number of days for which each provider is responsible for furnishing post-operative care.

However, there are various challenges for Cataract Post-Op Co-Management Claims

  • There is often confusion with the date of the patient visited the optometrist and the date of surgery
  • There is an incorrect use of Assumed Care Date (date postoperative care assumed by another provider) and Relinquished Care Date (date provider stopped postoperative care) from the office billers
  • The surgeon’s name and NPI were not listed on the claim as the referring physician.
  • Since the cataract post-op care was performed within the global period of the first postoperative claim, the office billers were not appending the correct modifier on the second postoperative claim to ensure both claims were paid correctly.
  • Before the optometrist filed the postoperative claim, the surgeon’s medical claim should have been filed to Medicare.
  • The claim was billed with 89 units instead of 1 unit for Medicare, which led to Medicare denying the claims.

We are here to help you solve these challenges to streamline your insurance claim process. These cataract post-op co-management guidelines are a great place to start on your path to healthier cash flow and fewer denials.


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