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Coding corner

Billing for routine perioperative care by hospitalists may require modifiers

By Brian Whitman

From the June ACP Hospitalist, copyright © 2008 by the American College of Physicians

Q: If a patient is having surgery and the hospitalists go to the floor or to the outpatient surgery unit to perform preop or postop assessment for the surgeon, can we bill? Or would this be included in the surgical package?

A: All surgical procedures are assigned a global period that immediately precedes and follows the surgical intervention. Procedures are assigned global periods of 0, 10 or 90 days. This question is most relevant to the 10- and 90-day global period.

The global period essentially starts on the day of the surgical intervention, but may include evaluation and management (E/M) services that are performed following the decision to perform the surgery. For the 10 or 90 days that follow the procedure, any E/M services related to the surgery are not separately billed. Surgical services are paid in part based on the average number of postoperative visits performed during the global period, so the payment for these E/M services is already included in the payment for the surgery.

If a physician who performed a surgery were to submit a claim to a payer for an E/M service during the global period, that claim would not be paid unless a modifier was attached that indicated why this service would not be considered under the global period. However, if a different physician is providing the service, the claim would not be automatically denied through payment edits and would be paid as submitted assuming all other requirements are met.

The question of whether this service is being paid appropriately depends on the nature of the service. If the services provided by the hospitalist would be considered to be part of a routine element of postsurgical care, then the surgeon is being paid for this service as part of his or her global fee. If, however, the surgeon requests a consultation or if the hospitalist is treating the patient for an unrelated medical condition, then that is an additional medical service for which the surgeon is not being paid.

A consultation requires that the surgeon request the hospitalist’s advice or opinion on how to address an issue. If care is completely transferred to the hospitalist, this would not meet the definition of a consultation.

A consultation requires that the surgeon request the hospitalist’s advice or opinion on how to address an issue. If care is completely transferred to the hospitalist, this would not meet the definition of a consultation.

If the hospitalists and surgeons have an arrangement in which the hospitalists (who are in separate group practice) are providing all of the routine preoperative and/or postoperative care (and therefore transferring care to the hospitalists), then the physicians must use modifiers to indicate this transfer. There are three modifiers that may need to be used in this situation, as follows:

• Modifier 54—Surgical care only
• Modifier 55—Postoperative management only
• Modifier 56—Preoperative management only

If the hospitalist provided the postoperative or preoperative care, then he or she would report the CPT code for the surgical procedure and use modifier 55 or 56. The hospitalist would then be paid for the percentage of the surgical payment that is considered to be for preoperative or postoperative management.

Brian Whitman is Associate for Regulatory and Insurer Affairs in ACP’s Washington, D.C. office. His column appears every other month. E-mail coding questions or issues to acphospitalist@acponline.org.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated