Billing for exams during the global period requires thorough knowledge of modifiers, documentation requirements and other details.
Here’s a look at three billing scenarios to help you receive the proper reimbursement, no matter who performed the initial procedure.
Scenario 1: Physicians in the Same Practice
When a patient presents for an unrelated condition during their global period, your documentation should focus on the new or current condition — not on reasons that relate to the postoperative period. If you document the history of present illness, it is imperative that you focus on the new complaint.
If the history states “here for postop exam,” you should not charge additionally for the exam.
For example, let’s say a patient who is in the global period following cataract surgery in her right eye presents for a glaucoma evaluation and pressure check. Your history, exam and medical decision-making should focus on the diagnosis of glaucoma.
Once you have clearly documented the new complaint/condition, submit the exam with modifier -24 Unrelated evaluation and management service by the same physician during a postoperative period. You can also append this if you bill with Eye visit codes. In this case, be sure to link the new diagnosis rather than the reason for the previous procedure.
If you treat a patient who is in the global period of a procedure performed by a partner in your practice, you might have to make some billing adjustments. If the condition is unrelated, you won’t need modifier -24 because you have a different National Provider Identifier (NPI) number than the operating physician.
However, if the condition is related and you are taking over the patient’s postoperative period, you cannot bill the exam separately. You can, however, bill any necessary testing or procedures separately without the use of any additional modifiers. Be sure to check with the payer for specific guidelines.
Scenario 2: Physicians in a Single Call Group
Many physicians from different practices set up a call group to help their colleagues with patient care. If you are one of these on-call physicians, whether you can bill for an exam to another group member’s patient depends on how your exam relates to the surgery.
If the exam is related to the other physician’s surgery, you can’t bill for an exam during the global period. As the on-call physician for the entire group, you are acting as the surgeon.
If the exam is unrelated to the other physician’s surgery, however, you can bill for the exam during the surgery’s global period. Keep in mind that you don’t necessarily need to append modifier -24. Although the call group serves as an extension of those physicians who are not on call, you are still billing under your own NPI.
Scenario 3: Physicians Outside Your Practice
A patient presents to your practice after having lid surgery in another state. He/she recently moved and now requires follow-up care. How should you, as the new physician, submit the claim?
If you have not established a co-management agreement with the previous physician, you should submit the exam with either an E&M or Eye visit code. You don’t need any additional modifier.
However, if you have a transfer-of-care agreement on file (see the Academy’s Learn to Code the Essentials for an example), you cannot bill for the exam. Instead, you must follow the co-management guidelines and append modifier -55 Postoperative management only to the procedure that was originally performed. In box 19, include the date on which you took over care for the patient. The billable amount will be 20 percent of the allowable for the surgery. You cannot bill separately for additional exams that are unrelated.
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About the authors: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Practice Management Express, Ophthalmic Coding Coach and Ophthalmic Coding series.