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Comanagement is a non-financial arrangement between a physician performing surgery and a comanaging physician who provides care to the patient for some portion of the global follow-up period. Comanagement is available for any procedure with a global period of 10 days or greater, and the rules remain the same irrespective of the length of the global period.
Comanagement of any surgery begins with the formal transfer of care from the surgeon to the comanaging physician—typically to the physician who originally referred the patient for a surgical evaluation. However, a referral cannot be based upon the requirement that the surgeon refer the patient back to the referring physician. In a comanagement situation, the patient chooses the comanaging physician, so be sure to discuss the arrangement with your patient before the initial surgical evaluation. Above all, the patient’s wellbeing is the most important factor to consider.
Each physician has certain protocols to follow. Have a clear agreement in place with the surgeon to establish the guidelines for communication, timely reports back to the surgeon and when the patient will be seen again after surgery. The surgeon should provide information on the surgery claim filed, so you can use the correct information for the postoperative care claim.
| Table 1. Diagnosis: H25.13 Age-Related Nuclear Cataract, Bilateral (OD/MD) | |||||||||
| Dates of Service | Place of Service | Type of Service | Procedures, Services, Supplies (Explain Unusual Circumstances) | Diagnosis Code | Charges | Days or Units | |||
| From MM/DD/YY | To MM/DD/YY | CPT-HCPCS -Modifier | |||||||
| 1 | 2/25/2015 | 11 | 92004 | A | $149.58 | 1 | |||
| 2 | 2/25/2015 | 11 | 92015 | B | $20.03 | 1 | |||
| 3 | 2/26/2015 | 11 | 76519-26-50 | A | $63.16 | 2 | |||
| 4 | |||||||||
| 5 | |||||||||
| 6 | |||||||||
Let’s look at coding for traditional monofocal IOL implantation.
Pre-cataract Surgery
In most cases, a comprehensive eye examination and a single diagnostic ultrasound A-scan to determine the appropriate pseudophakic power of the intraocular lens are sufficient (Table 1). For patients with a dense cataract, an ultrasound B-scan may be used.
Where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination and an A-scan or, if medically justified, a B-scan. Claims for additional tests are denied as not necessary unless there is an additional diagnosis and the medical necessity for the additional tests is fully documented.
Transfer of Care
The global surgery fee schedule allowance includes preoperative evaluation and management services rendered the day of or the day before surgery, the surgical procedure and the postoperative care services within the defined postoperative period. Postoperative care may be rendered by an ophthalmologist, optometrist or providers licensed to render such services. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to a receiving physician outside of their group practice at the time of referral, and the receiving physician documents approval of care in advance. Each provider must agree and document the transfer of care in the medical record. The agreement must be in the form of a letter or written as a notation in the discharge summary, hospital records or ambulatory surgical center records.
The appropriate CPT-4 modifiers must be added to the surgical procedure code:
- -54 surgical care only
- -55 postoperative management only
- -79 unrelated procedure or service by the same physician during the postoperative period
The claim for surgical care only and postoperative care only must identify the same surgical date of service and procedure code. For claims where physicians share postoperative care, the assumed and relinquished dates of care must be indicated in Item 19 of the CMS-1500 claim form, or electronic media claim equivalent. When more than one physician bills for the postoperative care, the percentage is apportioned based on the number of days each physician was responsible for the patient’s care. The maximum percentage for postoperative care for 66984 is 20%, and the length of the associated global period is 90 days.
The diagnosis for cataract is the most appropriate for clinicians to use for postoperative care. In the ICD-10 system, practitioners should consider categories H25.xxxx, H26.xxxx, H28.xxxx and Q12.0.
Comanagement Coding
Dr. Smith’s claim contains:
Dr. Smith’s claim contains:
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The Postoperative Period: Always 90 Days?
Ninety days is the most common global period for procedures such as cataract surgery. But it can vary depending on the procedure. For example, punctal occlusion has a global period of 10 days. The optometrist responsible for the postoperative period provides all care during this designated time, whether it’s 90 days or 10, without billing extra fees.
However, if a patient develops a new medical condition unrelated to the surgery during the postoperative period, that care is not considered part of the postoperative care. This 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).
If a complication of surgery occurs, the care is considered part of the postoperative period and cannot be billed separately. Other procedures such as an OCT would be billable.
The Centers for Medicare and Medicaid Services (CMS) calculates the reimbursement fee for comanagement, generally, at 20% of the total allowed fee for the surgery if care is provided for the entire global period; however, this can vary based on procedure. Otherwise, the reimbursement fee is prorated based on the number of days care is actually performed during the postoperative period. Some private insurers and Medicare Advantage plans may use a different calculation, so check before providing postoperative care.
Farewell to Global Periods
In 2014 CMS proposed the elimination of global periods because the Office of the Inspector General identified a number of surgical procedures that include more visits in the global period than are actually being furnished, thus creating greater costs to the system than are medically necessary. To address this, beginning in 2017, CMS has proposed the inclusion of all services provided on the day of surgery and to pay separately for visits and services furnished after the day of the procedure. So, comanagement isn’t ending, but the single global payment and the 20% value assessment is. In 2017 the comanaging physician will provide only the postoperative visits that are medically necessary and bill for them individually.
Comanagement is great opportunity, allowing us to provide great care to our patients beyond our current scope of practice—not to mention collaborate with peers and colleagues.
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