The Chaos of Comanagement

Comanagement is a non-financial arrangement between a physician who performs surgery and a comanaging physician who provides care to the patient for some portion of the global follow-up period. The physician who performs the surgical procedure is usually an M.D., but in some cases is an O.D. The comanaging physician can be either an M.D. or an O.D., as well.

The 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 to a surgeon cannot be based upon the requirement that the surgeon refer the patient back to the referring physician.

In a comanagement situation, it’s the patient who is actually the one to choose the comanaging physician. Be sure to discuss the comanagement arrangement with your patient before the initial surgical evaluation. Above all, the patient’s wellbeing is the most important factor to consider in any surgical referral and comanagement arrangement.

Each physician plays a key role and has certain protocols to follow. Have a clear agreement in place with the surgeon to establish the guidelines for communication, for timely reports back to the surgeon, and when the patient will be seen again after the surgery. The surgeon should provide information on the surgery claim filed, so the correct information for the postoperative care claim can be used.

Each regional Medicare carrier may have its own policies for comanaged arrangements in local coverage determinations, which need to be followed when performing and filing postoperative care. But, some basic rules are common when billing for this care:

• When providing preoperative care, file the appropriate CPT code with the -54 modifier to indicate preoperative care only.
• When providing postoperative care, file the appropriate CPT code with the -55 modifier to indicate postoperative care only.
• 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 must also be listed on the claim.

The Postoperative Period: Always 90 Days?
Each surgical procedure has a specific global or postoperative period. Ninety days is common, particularly for cataract surgery. However, a procedure like punctal occlusion has a global period of 10 days. The physician responsible for the postoperative period is expected to provide all postoperative care during this designated period without billing extra fees.

But, if a patient develops a new medical condition that is unrelated to the surgery during the postoperative period, that care is not considered part of the postoperative care. This 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).

However, 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.

The Centers for Medicare & Medicaid Services generally calculates the reimbursement fee for comanagement at 20% of the total allowed fee for the surgery if care is provided for the entire postoperative period. But, this total percentage can vary based upon the procedure; otherwise, the reimbursement fee is prorated based upon the number of days that care is actually performed during the postoperative period. Some private insurers and Medicare Advantage plans may use a different calculation, so be sure to know before you provide postoperative care.

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