Modifier 54 for Profee - does this change global days for claim processing?

Hello
If modifier 54 is appended to a major surgery CPT (global day 90), how would subsequent claims be processed? Specifically, would subsequent claims for the next 90 days be processed as occurring within the global day period? Or would the procedure be considered a zero day global because mod 54 was submitted indicating only intraoperative and preop services? Also, when using mod 54, would modifier 57 or 25 be used for the E/M code since we are billing only for the pre and intraop portion (assuming E/M reporting is appropriate of course). This occurs frequently in the Emergency Room

Specific example: Dislocated shoulder reduction billed with mod 54. Pt returns two months later for recurrent dislocation of same shoulder and reduced again - not sure how to code and append modifiers for second visit . Or, fracture reduction with mod 54, with subsequent visit for laceration repair and/or another fracture reduction

I have poured over the CMS Claims Processing Manual for global period claim processing and the CMS Outreach info on global day billing to find the official supporting guidance on this. Any references would be greatly appreciated.

Thank you
Bridget Smith, RHIT

Comments

  • I did find CPT Assistant Coding Brief which recommends mod 25 for the ED physician when billing mod 54 on the procedure as well as the return trip to the ED within 90 days (Nov 2016 CPT Assist). However, as we know, Medicare/Claim processing my conflict with this. Will use the CPT advice until I find out otherwise or recommendations from this group. thanks

  • Just curious: How did the patient come back to the surgeon if the surgeon handed off for post-op -- as 54 suggests? Did the post-op provider (55) send the patient back?

  • I believe she said that it was a recurrent dislocation of the same shoulder...

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