As defined in earlier columns, comanagement is a non-financial arrangement between the doctor performing surgery and a comanaging doctor who provides care to the patient for some portion of the global follow-up period. The doctor who performs the procedure is generally an MD, but in some cases is an OD. The comanaging doctor can be either an MD or an OD as well.
Let’s look at some questions that have arisen (in my Inbox) since the last time we covered this topic.
• “How do I bill a follow-up office encounter for one of my patients who has had cataract surgery within the 90-day global period, when I have not been designated as the comanaging physician?”
Before I answer that question, let’s keep in mind some basic principles about the comanagement relationship. The comanagement of any surgery begins with the formal transfer of care from the surgeon to the comanaging physician. This transfer is typically, but not always, to the physician who originally referred the patient for a surgical evaluation. Remember, a referral to a surgeon cannot be based upon the requirement that the surgeon refer the patient back to the referring physician. In fact, in a comanagement situation, it’s actually the patient who is the one to choose the comanaging physician.
However, I’ve seen an increasing trend among surgeons to keep the patient without designating a separate comanaging physician. Normally, if the surgeon is going to comanage the care of the patient, the surgeon bills the surgery with the component codes 6698X-54 (for the pre- and intraoperative portions) and 6698X-55 (for their prorated portion of the follow-up care). The surgeon also places a date of release to the comanaging physician in box #19 of the CMS 1500 form.
Now, if a surgeon is not comanaging with anyone, then the surgeon can simply bill 6698X without any modifiers, thereby telling the carrier that he or she is performing the pre-, intra- and postoperative care for the entire 90-day global period.
OK, so back to the question. What happens when the patient returns to your office? First, because you have never been designated as the comanaging physician, you are not bound by any of the rules of comanagement. Your office visit could be coded as a 9201X or 9921X, depending on the reason for the visit and the appropriate level of case history, physical examination and medical decision-making you performed. You are not bound to accept any reimbursement related to the surgical “comanagement” at all.
However, I believe that you have an obligation to let patients know that their follow-up care related to the surgery is already covered for the 90-day period after their surgery. But keep in mind that the patient always makes the decision of who they want to see, period! So, if the patient chooses to see you, provide the appropriate level of care required by the patient’s presentation and bill the carrier accordingly.
• “How do I, when I am designated as the comanaging physician, code an office visit within the global period following cataract surgery that is not related to the cataract surgery?”
This is an easy one. Let’s refer to Appendix A of the 2013 CPT book, which contains the modifiers and their definitions. In this case, modifier -24 is the correct one to append to the office visit.
Specifically, “the physician or other qualified health provider may need to indicate that an evaluation and management [E/M] service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.”1
Remember that this applies to both the 920XX and 992XX codes, as the 920XX codes are considered part of the E/M code set.
Simple questions with not-so-simple answers; but, hopefully, these are ones that will aid you in your day-to-day patient care.
Meantime, it’s T minus 10 months and counting until the Affordable Care Act officially kicks in. More on that next month.
1. Current Procedural Terminology (CPT) Professional Edition. Chicago: American Medical Association; 2013:595.