Surgical Co-Management (Modifiers 54 and 55)

Medicare covers surgical co-management for appropriate reasons such as inability of the operating surgeon to provide postoperative care, inability of the patient to return to see the operating surgeon in the postoperative period for a variety of reasons or patient preference. For example, one physician may perform the surgery, but another physician may provide the follow-up care. Medicare will pay no more than the total fee schedule approved amount for the surgical procedure regardless of the number of physicians involved. Co-managed care should always adhere to the basic tenets of good patient care, the ethical responsibilities of providers and governmental rules.

When physicians agree on the transfer of care during the global period, use the following modifiers:
* 54 for surgical care only.
Or,
* 55 for postoperative management only.

Providers do not need to specify on the claim that the care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field/free text segment on the claim form/format. Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. (Pub. 100-4, Chapter 12, Section 40.2 of the Internet-Only Manual (IOM)).

When a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he has provided at least one service. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he assumes care of the patient.

Exceptions:

* When a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate evaluation and management code. No modifiers are necessary on the claim.

* If the transfer of care occurs immediately after surgery, the physician other than the surgeon who provides the in-hospital postoperative care bills 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 bills the surgery code with the 54 modifier.

* Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of office visit code. The physician who performs the emergency room service bills 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. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.

Care Provided in Different Payment Localities
If portions of the global period are provided in different payment localities, the services should be billed to the Medicare contractor servicing each applicable payment locality. For example, if the surgery is performed in one state and the postoperative care is provided in another state, the surgery is billed with modifier 54 to the contractor servicing the payment locality where the surgery was performed, and the postoperative care is billed with modifier 55 to the contractor servicing the payment locality where the postoperative care was performed. This is true whether the services were performed by the same physician/group or different physicians/groups.

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