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Posted By Amanda on 01-16-2002, 15:10:00 in Ophthalmology
If a patient shows up to our office and states that she had surgery at
another location and needs someone to do her follow-up are we required to
bill as if we are co-managing? We had never seen this patient for this
condition and weren't aware of her having surgery. We feel that we should be
able to just bill based on what we've had to do at each visit.

We don't even know if the other doctor used the modifier 54?

Could we do what ever is best for us (money)?

Amanda
Comments (5)
Posted By douglas on 01-17-2002, 21:02:00
I stand corrected. The -24 modifier needs to be used only by the physician
who did the surgery and charged for the post-op care, and the meaning of the
-24 is that you are providing some service unrelated to the post-op care for
which you have already been paid. I didn't have my thinking cap on when
making the previous answer. Sorry.

Douglas R. Anderson
Posted By douglas on 01-17-2002, 19:30:00
Agree. If the patient came to you for an urgent condition unrelated to
post-op care, no problem to bill with a modifier -24 to indicate to the
carrier that this visit is unrelated to recent surgery. Or, if you take the
patient to the O.R. (or laser suite) to fix a complication, you can also
bill.

The initial question, however, is what to do if the patient comes for
post-op care and you were not the surgeon. That is a problem. And as has
been indicated, it may be that the patient had reasons for not going back to
the surgeon, even though the surgeon had planned to provide the post-op care
himself. As that is possible courtesy is to be afforded to the surgeon if
you call in order to sort out the circumstances, but you have a right to
have a dim viewpoint of his character if it turns out he dumped the patient.

Doug Anderson
Posted By michael on 01-17-2002, 03:44:00

In a message dated 1/16/02 2:59:48 PM, danderson@med.miami.edu writes:

<< Sorry, the question was about billing, not ethics. So, yes, call the

surgeon and ask him what his post-op care plans were, get him to bill

correctly and maybe threaten to report both his improper billing but poor

patient care to wake him up. Do it carefully, however, because it may be he

planned to take care of the patient but the patient decided not to go back

to his office for some reason and he may not be at fault.


Douglas R. Anderson >>

If the patient comes to you for an emergency unrelated to the original
surgery, because he couldn't get hold of his surgeon, or is out of town,
could you bill the visit with a -24 modifier? Or if surgery or laser is
needed, use a -79 modifier (or-78 if related to the original surgery)?--and
get paid?

Dr. Yaros
Posted By michael on 01-17-2002, 03:39:00

In a message dated 1/16/02 2:41:13 PM, jbell@mint.net writes:

<< If you bill Medicare for services related to surgery during the post-op

period your claim will be denied as duplicate since the surgeon has already

been paid for post-op services as part of the global fee. About the only

thing that I am aware you can do is to contact the surgeon's office and have

them rebill with the -54 modifier so that you can get paid for the post-op

care. Then the surgeon's office would have to bill with the -55 modifier for

any post-op care that office provides.

John S. Bell,CEO, COE >>

I think the question is why the patient shows up at your office after the
surgery by another doctor. If you haven't been sent the patient for an
opinion or as a comanage arrangement in advance, the other doctor may not
even know the patient is there. You could have the patient sign a form that
the visit might not be paid for. You could contact the other doctor to
resubmit with the -54, but the patient may not want the other doctor to know
they saw you.

Dr. Yaros
Posted By douglas on 01-16-2002, 19:01:00
There are some other things to discuss here besides billing. Somehow it is
just fundamentally wrong for a surgeon to perform surgery without a plan for
the post-op care understood by all parties. The patient should not go from
office to office seeking post-op care, being turned away potentially by
physicians who worry they won't get paid. That's called abandoning the
patient, and is against the law as far as I know. Even if the surgeon did
the surgery for free. Once a doctor accepts a patient and cares for him, he
must be available for further care unless he gives ample notice to the
patient that he will after (date) he will no longer be his doctor.

Although apparently not a federal legal standard, some ophthalmic
organizations have indicated that they feel the ethics of co-management
require that arrangements are made in advance, that the surgeon see the
patient at least once, and that he release the patient to the co-manager at
a time determined by the patient's course. Moreover, that it be for
patient's benefit or convenience (he lives far away) that the surgeon
solicits the help of someone else to help care for the patient after he is
stable enough for the other person to take over. These rules however
generate from an ethics statement of ophthalmic organization and are
sometimes confused as being billing rules, which I don't think impose these
requirements. Billing rules are only that you can't bill for something
twice, and if the surgeon was paid already a global fee for surgery and
post-op care, the insurance carrier is not going to pay a second time for
the post-op care. In fact, if the surgeon does care for the patient for 1
month (for example) and someone else then takes over, the payment for
post-op is supposed to be split one-third to the surgeon and two-thirds to
the other doctor, but it all gets too complicated and I doubt anyone ever
really does this.

There are political overtones to the "ethics" rules, and not all
ophthalmologists are in agreement over the principles behind co-management.
Billing rules are clear. But for goodness sake, the welfare of the patient
should be prime.

Sorry, the question was about billing, not ethics. So, yes, call the
surgeon and ask him what his post-op care plans were, get him to bill
correctly and maybe threaten to report both his improper billing but poor
patient care to wake him up. Do it carefully, however, because it may be he
planned to take care of the patient but the patient decided not to go back
to his office for some reason and he may not be at fault.

Douglas R. Anderson

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