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BUSINESS: CODING STRATEGY

REVISIT POST-OPERATIVE CARE

COMMUNICATE AMONG PHYSICIANS AND UNDERSTAND CODING PROCEDURES

A NON-FINANCIAL arrangement between two physicians, one who is performing surgery and one who is providing care to the patient for some portion of the global follow-up period. This is how co-management is defined by CMS. It is available for any procedure with a global period of 10 days or greater — utilizing the same rules.

TRANSFER OF CARE BETWEEN PROVIDERS

The co-management of any surgery begins with the formal transfer of care from the surgeon to the co-managing physician — typically, to the physician who originally referred the patient for a surgical evaluation. However, a referral to a surgeon CANNOT be contingent on the requirement that the surgeon refer the patient back to the referring physician.

In co-management, it’s the patient who chooses the co-managing physician. Be sure to discuss this with your patient to fulfill your legal obligation to inform him or her of the options prior to the initial surgical evaluation. Above all, the patient’s wellbeing is the most important factor.

UNDERSTAND CODING REQUIREMENTS

Each physician plays a key role and has certain protocols to follow. Clear communication is important to this relationship as you will need:

  • to receive timely reports,
  • to identify when the patient will be seen after the surgery and
  • to ascertain information on the surgery claim filed, so the correct information for the postoperative care claim can be used.

Ordinarily, the global surgery fee schedule allowance includes preoperative evaluation, management services rendered the day of, or the day before, surgery, the surgical procedure and the postoperative care services within the defined postoperative period, according to CMS.

In the case of postoperative care, it may be rendered by an ophthalmologist, optometrist or providers who are licensed to render such services.

A “transfer of care” occurs when a physician transfers the responsibility for the patient’s complete care to another provider outside his or her group practice, via referral, within the global period and the receiving physician documents approval of care in advance. Each provider must agree to and document the transfer of care in the medical record. The agreement must be in the form of a letter or written as a notation in the discharge summary/hospital records or ambulatory surgical center records.

The claim for the surgical care only and the claim for the postoperative care only must identify the same surgical date of service and the same surgical procedure code.

The appropriate CPT modifiers must be added to the surgical procedure code:

  • -54 Surgical care only
  • -55 Postoperative management only
  • -79 Unrelated procedure or service by the same physician during the postoperative period

For claims where physicians share postoperative care, the assumed and/or relinquished dates of care must be indicated in Item 19 of the CMS-1500 claim form, or electronic media claim equivalent.

Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has seen the patient and provided at least one service.

When more than one physician bills for the postoperative care, the postoperative percentage is apportioned based on the number of days each physician was responsible for the patient’s care.

In co-management, the patient chooses the co-managing physician. Communicate this with your patient to fulfill your legal obligation.
PHOTO CREDIT: YakobchukOlena/stock.adobe.com

WHAT DOES THE FUTURE HOLD?

With the passage of Medicare Access and CHIP Reauthorization Act in 2015, CMS moved forward efforts to end the global period concept and replace it with a model of pay-per-service rendered.

That said, there is a new reporting mechanism for those living in Florida, Kentucky, Nevada, New Jersey, North Dakota, Ohio, Oregon and Rhode Island.

Beginning July 1, CMS has required qualified doctors in these states to report CPT code 99024 (postoperative follow-up visit) when the doctor sees a patient during the postoperative period related to co-management. Doctors in other states are not required, but can voluntarily report that information as well. (Please note that there are specific guidelines and exemptions for this code that you will need to know before moving ahead.) This provides a mechanism for CMS to evaluate the actual number of visits required for appropriate post-operative care and the cost impact to the system.

UNDERSTAND THE CLIMATE

Co-management is a vital part of optometric practice. Understanding the current and future aspects of providing it is critical to patient outcomes and the success of your practice in the outcome-based world of health care. OM