When optometrists think of surgical comanagement, they usually think of cataract surgery. But, comanagement of surgical care can extend to other ocular surgeries, including YAG laser capsulotomy, trabeculectomy and retinal detachment repair, to name a few.
The comanagement of any surgery begins with the formal transfer of care from the surgeon back to the optometrist—typically to the optometrist who originally referred the patient for a surgical evaluation. Above all, the patient’s well-being is the most important factor to consider in any surgical referral and comanagement arrangement. Be sure to discuss the comanagement arrangement with your patient before the initial surgical evaluation.
You should also have a clear agreement in place with the surgeon to establish the guidelines for communication, your reports back to the surgeon, and when you’ll see the patient again after the surgery. The surgeon should provide you with information on the surgery claim filed, so you have the correct information for the postoperative care claim.
Each regional Medicare carrier may clearly lay out its policies for comanaged arrangements in local coverage determinations (LCDs), as well as in National Coverage Decisions (NCDs). The LCD for your carrier can be found on the regional carrier’s website or on the Centers for Medicare and Medicaid (CMS) website ( www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp), or from commercial vendors such as www.LCDPlus.com. The other formal methods of communicating guidelines for care can be found in the regional carrier articles and in the MLN Matters articles published by CMS. (Although CMS does issue NCDs for intraocular lenses and phacoemulsification, there is no NCD for comanaged surgical care.) While each regional carrier has specific rules that need to be followed when performing and filing postoperative care, there are some basic rules that are common when filing this care:
• When providing preoperative care, file the appropriate CPT code with the -54 modifier to indicate filing only preoperative care.
• When providing postoperative care, file the appropriate CPT code with the -55 modifier to indicate filing only postoperative care.
• Indicate the specific eye using the -RT or -LT modifier.
• When a second surgery is performed during the postoperative period of the first surgery, the -79 modifier is used to indicate that the filing is for an unrelated procedure or service by the same physician during the postoperative period. The surgeon’s name and National Provider Identifier (NPI) number are listed on the claim.
Some private insurers and Medicare Advantage plans may vary their definition of the postoperative period, but most follow the CMS definition of 90 days. The provider responsible for the postoperative period is expected to provide all postoperative care during this designated period without billing extra fees.
So, if a complication of the surgery occurs, the care for this complication is considered a part of the postoperative period and cannot be billed separately.
However, if a patient develops a new medical condition during the postoperative period unrelated to the surgery, that care is not considered part of the postoperative care. The unrelated care can be billed separately using the -24 modifier for office visits or the -79 modifier for new surgical procedures (such as a foreign body removal).
CMS calculates the reimbursement fee for comanagement at 20% of the total allowed fee for the surgery. Some private insurers and Medicare Advantage plans may use a different calculation, so be sure to know prior to providing the postoperative care.
Once your fees have been set, this is the amount you must charge every patient regardless of the insurance reimbursements.
