Comanagement, or shared care of a surgical patient, is a legal and ethical practice. This was officially recognized by the Centers for Medicare & Medicaid Services (CMS) in 1992. CMS states that surgical comanagement is appropriate under many conditions, including a variety of reasons or patient preference.
Optometrists have the privilege and right to participate in the postoperative management of their patients. Frustration with comanagement often comes from difficulty in being reimbursed for postoperative services.
Here are some common questions on comanagement and, more specifically, how to be reimbursed for your services.
How Do I Participate?
Lets start with what CMS defines as the Global Surgery Package. In general, a Global Surgery Package is designed to reimburse the surgeon and any other provider participating in properly transferred postoperative care. This single fee includes:
Any preoperative visits performed after the decision is made to operate. This typically is considered one day before a major surgical procedure.
Intraoperative services.
Postoperative evaluations, including services provided for normal recovery from the surgery or for complications related to the surgery.
Supplies and miscellaneous services (e.g., surgical trays, suture removal, aqueous tap to relieve elevated IOP after cataract surgery, etc.).
Global Surgery Package comanagement percentages are generally set by CMS, as contained in the characteristics table of the CPT code. Each surgical CPT procedure generally has a pre-surgical, intra-surgical and post-surgical portion that is assigned to the single global reimbursement. The post-surgical portion is generally 20% of the total reimbursement. If more than one provider participates in the postoperative care, the total fee paid to both providers cannot exceed the fee that would have been paid if a single doctor provided all the postoperative care.
An important point to remember: Comanagement cannot occur unless there is a written transfer of care from the operating surgeon to the doctor who is providing part or all of the postoperative care. Both doctors maintain the written agreement in their files. A written agreement with the patient is not a CMS requirement, but its a good idea.
How Do I File a Claim for Comanaged Care?
The split of the Global Surgery Package reimbursement is accomplished by the use of the -54/-55 modifiers. The operating surgeon attaches the -54 modifier to the surgical code, and the comanaging doctor attaches the -55 modifier to the same surgical code.
Both providers must accurately communicate with each other to ensure that the information provided on their respective claims does not conflict. This is one of the main reasons that carriers reject claims for comanaged services. Surgical codes, surgical dates, release dates and days of service must all match exactly between the operating surgeons claim and the comanaging doctors claim.
You may calculate the approved fee exactly (20% of surgical fee multiplied by the number of days you were responsible for the patient, divided by 90), or you may estimate it. If you estimate the fee, realize that Medicare will pay you the highest of the approved fee or your submitted fee. Per CMS rule, the comanaging doctor cannot submit a claim for reimbursement until he or she has actually examined the patient at least once.
ITEM 19 21 24a-b
24f 24g Note: Check with your carrier for local deviations from the guidelines in this table, especially with the use of Item 19.
CMS-1500 Claim Form or Electronic Equivalent
ENTRY
17
Operating surgeons name and NPI.
Dates of Global Surgery Package (must match operating surgeons dates).
ICD for the surgery performed (must match ICD used by operating surgeon).
Dates of service (release date to end of Global Period).
Surgical CPT-55, RT or LT (must match CPT used by operating surgeon).
Fee.
Number of days care provided (must be exactly as noted in 24a-b).
Also, if the claim is for comanaged care for surgery performed on the second eye during the Global Surgery Package of the first eye, attach modifier -79 to Item 24d.
Whats Not Included in the Global Surgery Package?
Global surgery fees dont require that all ocular care for that patient must be billed together during this period. The package excludes patient evaluations and diagnosis of conditions that are unrelated to the surgery and are not a part of normal recovery from surgery.
If youre participating in the postoperative care of the patient, services not included in the Global Surgery Package are billed with the -24 modifier attached to the evaluation and management service and the -79 modifier attached to any diagnostic procedures performed.
If all or part of the patients postoperative care has not been transmitted in writing to you, the modifiers are not needed. A very important concept to remember is that the Global Surgery Package applies only to the operating surgeon and any other provider to whom he or she releases the patient for post-op care. Unless you are formally participating in the patients postoperative care, you can provide whatever services the patient needs and not be limited or restricted by the global period limitations.
As with any billing and coding issue, become a comanagement reimbursement expert yourself by reading the rules established by CMS and your carrier. CMS guidelines can be found in Section 40.2 of the Internet Only Manual at www.cms.hhs.gov/Manuals/IOM. Your carrier will also have a Web site on which the information is easily obtainable.
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