-54/55 Modifier use

Same practice, then the performing surgeon bills their service, says it is CPT 28296, they would append Modifier 54, meaning they only did the surgery and you provide the global 90 post-op care meaning you bill same CPT code but you append Modifier 55. As for exposure, you are a party to the surgery even though you are not performing this procedure and remember you are rendering care related to the surgery. You should reach out to your malpractice carrier to make sure the medmal policy that you have covers you in these circumstances.

I am assuming the physician who is performing these procedures is not part of your group. If that is the case, then the surgeon bills using the normal CPT code(s) they would use for those procedures and amends them with a 54 modifier.

Since you are providing the post operative care, you or your group would bill the same CPT codes as your surgical colleague, who is not part of your group and amend the same set of CPT code(s) with a 55 modifier.

It is important to remember that every surgical CPT has three components, pre operative evaluation, the actual performance of the procedure (intra-op) and post-operative care.

Technically if the surgeon is not providing the post operative care and billing for the entire global component of the procedure, then they are being overpaid. This because they are being reimbursed for procedures they did not actually perform (post operative care).

As for the last question alluding to the medical legal ramifications, I defer to your attorney. But here is some friendly advise, it would be best to get an attorney to advise you on your specific exposure, as this may be different depending on the state and the nature of the allegations.

For example, you would have a large exposure if the allegations were that you did not properly diagnose and treat a post operative infection, displaced capital fragment etc. as you actually are both diagnosing and managing these situations.

Allegations for a patients undergoing a medically unnecessary procedure could also be made against you, even though you did not actually perfrom the procedure. This expectially if you were the physician who referred the patient for a specific procedure. For example, if you simply referred a patient for bunionectomy but did not refer the patient for a specific bunionectomy, the plaintiff's attorney might have a more difficult time proving their case than if you referred the patient for a lapidus which was not needed.

Your exposure should be less if the primary allegations were that the sugery was was not properly performed. For the latter, since you werer not physically present for the surgical procedures, you could be excused. But a good plaintiffs attorney might be sucessful in proving that you knew and should not have referred the patient to a less than competent physician.

As you can see this can get very complicated because in reading hundreds of depositions plaintiff's attorney rarely if ever accuse you of one act of deviation from the standard of care and malpractice.

Let's end this part of the discussion where we started. Have your health care attorney and professional liability carrier proactively work with you to limit your exposure before you engage the surgeon.