Can Two Practices Split the Post-Op Office Care of a Patient?

Question:

Can two practices split the post-op office care of a patient?

Answer:

No. Although the operative and post-operative portions of the global package may be split between two groups, there isn’t any way to split the office post-op visits between two practices.

CMS developed a single payment for global surgery that includes certain pre-op services, intra-operative services and post-op services.

The value assigned to the CPT^® code includes post-op care. Inpatient post-op care is valued as part of the intra-operative care for services that typically have an overnight stay. The value of the outpatient post-op care is assigned for each surgical CPT^® code in the Medicare Fee Schedule.

CPT^® has a mechanism for splitting the surgical care from the post-op care through the use of modifiers 54 and 55. In order to do this, both the surgeon who performs the surgery and the surgeon who does the post-op care report the same CPT^® code with the same date of service. The operating surgeon appends modifier 54 and the post op care surgeon appends modifier 55. The payer splits the fee between the two physicians/groups according the percentages in the Medicare Fee Schedule.

There is no provision for splitting the outpatient post-op care. Notice the last paragraph. Although occasional post-op visits done by another physician may be paid or denied, this isn’t payable as a regular occurrence.

From the CMS manual:

D. Physicians Furnishing Less Than the Full Global Package 
B3-4820-4831

There are occasions when more than one physician provides services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the postoperative, post-discharge care is split between two or more physicians where the physicians agree on the transfer of care.

When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services (except where stated policies, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care, result in payment that is higher than the global allowed amount). 
Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.

Post op visits by a covering surgeon

Question:

If a vascular surgeon provides coverage for a general surgeon and sees a patient (inpatient) in the post op period is that service billable or is it considered post op?  The patient isn’t having a vascular issue or an emergency. If the general surgeon were rounding that day the services would be post op.

However, since the vascular surgeon is from a different specialty is the follow up service billable as a subsequent hospital visit?

Answer:

Although the payer might process the claim and pay it, it is incorrect to bill for it, regardless of the specialty of the covering physician. This is routine post op care, and is included in the global payment.

Your surgeons will want to see it in writing, with a citation.

Here is what CPT says:

“In the instance where a physician/qualified health care professional is on call for or covering for another physician/qualified health care professional, the patient’s encounter will be classified as it would have been by the physician/qualified health care professional who is not available.”

CPT 2024 Professional Edition, page 4.

Questions about the global package? Browse this list of articles and resources on modifiers. And members can download the Global Coding Guide.

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