Lately, many physicians have been debating whether they really want to co-manage postoperative care. This concern been refueled by a number of recent developments:

�        The Office of Inspector General (OIG) has expressed concern over potentially abusive referral arrangements.

�        Some Medicare carriers have published bulletins detailing specific and limited circumstances under which they consider co-management a covered service. These policies don't affect all parts of the country, but they represent shifting sentiment and may indicate future changes.

�        Various professional societies have published position papers on the subject. All of them agree that a referral should be based on what's best for the patient, but some groups place a greater significance on patient choice than others. These papers have helped to perpetuate mixed opinions within the ophthalmic community.

Minimizing legal exposure

Yes, the government has stated that co-managing postoperative care isn't illegal, and Medicare's official rules have been spelled out for some time. But most physicians are acutely aware that co-managing still carries an element of risk, and increased government scrutiny is likely.

To protect yourself and your practice, you should develop co-management protocols to ensure that your practice abides by existing laws and regulations. In this article (part one of two on co-management), I'll share a case history that illustrates proper protocols for co-managing Medicare-covered services -- in particular, cataract surgery.

Co-managing cataract care: a case study

Sally Ford is a 68-year-old woman who presents in Dr. Dodge's office for the first time. She says that Jeffrey Kelly, O.D., her longtime optometrist, has suggested an evaluation of her poor vision to see whether she needs cataract surgery. (Dr. Kelly is a local optometrist who frequently refers patients to Dr. Dodge.) Ms. Ford complains that she finds it difficult to read the newspaper and she's afraid to drive at night. She says that Dr. Kelly believes Dr. Dodge is the best surgeon to treat her.

Dr. Dodge's examination of Ms. Ford reveals visually significant cataracts, especially in the right eye. The remainder of her eye exam is within normal limits, and she's in good health.

Dr. Dodge explains that her poor vision and lifestyle difficulties are the result of her cataracts and that she'd benefit from cataract extraction with an intraocular lens implant. He explains the risks and benefits of cataract surgery. Ms. Ford decides to proceed with surgery on her right eye.

Let's suppose that Dr. Dodge is willing to co-manage this patient with Dr. Kelly. In order to protect himself, he should take the following steps.

Step one: patient consent

It's crucial to understand that the co-managing decision must be made by the patient -- not the physicians.

Prior to surgery, the patient must give informed consent for the procedure. This includes being informed about proper care following the procedure: the need for post-op care, what post-op care entails, and the choices of qualified professionals to provide post-op care. (This discussion may have been initiated in the optometrist's office, but all the key points should be restated and all options explored with the surgeon.)

In our case study, Ms. Ford has an established relationship with her optometrist and may desire to be followed by him after her surgery. After being informed of the risks, benefits and logistics of a transfer of care, Ms. Ford should be the one to make the request to be followed by Dr. Kelly. Most importantly, she should be given a choice -- and her choice must be honored.

Step two: postoperative care request form

A signed, written record of Ms. Ford's request for shared postoperative care is an effective way to document her consent. (Some Medicare carriers mandate this.) It should include:

�        documentation of the patient's willingness to have post-operative care provided by a different doctor

�        an acknowledgement that the benefits and risks have been explained

�        the reason(s) the patient wants to be followed by someone other than the surgeon

�        acknowledgement that the patient understands the logistics of the arrangement

�        an authorization for the providers to share information relating to the patient's health and vision

�        an acknowledgement that the patient has been advised of the other doctor's qualifications to provide care

�        an agreement that the patient will be returned to the surgeon in the event of a complication.

The patient, surgeon and co-managing physician should all sign and date the form. The form should then become a part of the patient's permanent medical record in both offices.

Note: It's unwise to establish an agreement between the surgeon and the receiving doctor without obtaining the patient's consent before the procedure.

Billing for post-op care

Ms. Ford decides that she'd like to be followed by Dr. Kelly after her surgery and signs the postoperative care request form. She has uneventful cataract surgery on August 1 and sees Dr. Dodge for postoperative visits on August 2 and August 11.

At her second postoperative visit on August 11, Dr. Dodge determines that it's clinically appropriate to transfer the remainder of her postoperative care to Dr. Kelly. He tells Ms. Ford that she should see Dr. Kelly in about 3 weeks.

How should each doctor bill Medicare for services rendered? Instructions provided by HCFA in May 1992 include several key points:

�        co-management requires a written transfer agreement between the surgeon and the receiving doctor(s)

�        claims must use specific modifiers (-54 and -55)

�        the receiving doctor can't bill for any part of the service included in a global period until (s)he has provided at least one service.

To abide by these regulations, the doctors in our example would take the steps outlined below.

Step three: transfer agreement

Medicare regulations require that the surgeon send a written transfer agreement delineating the split of postoperative care to the receiving doctor.

It's a bad idea to create an agreement such as this with the intention of using it for future patients as well; it's nearly impossible to predict future events with any certainty, and a prearranged split connotes payment for referrals and a possible illegal arrangement. Instead, a unique transfer agreement should be constructed for each patient.

Dr. Dodge's written transfer letter to Dr. Kelly should include the following key points:

�        the patient's name

�        the operative eye

�        the nature of the operation

�        the date of surgery

�        clinical findings

�        discharge instructions

�        the transfer date.

(See "Sample Transfer Agreement,")

Step four: acknowledgement from the receiving doctor

Dr. Dodge can't be certain that Ms. Ford will actually keep her appointment with Dr. Kelly, so Dr. Kelly should send a letter to Dr. Dodge following her first visit, containing:

�        the patient's name

�        the operative eye

�        the nature of the operation

�        the transfer date

�        the results of the first postoperative visit to his office.

The most important aspect of this letter is that it provides evidence that the receiving doctor, Dr. Kelly, actually saw the patient, Ms. Ford. This is in keeping with HCFA's requirement that he provide at least one service before billing.

Both doctors should retain copies of these letters as part of the patient's permanent record. They could also serve as a useful attachment on claims for reimbursement (if necessary).

Dividing the post-op payment

The overall value of postoperative care for ophthalmic surgery is 20% of the value of the global surgery package. Medicare subdivides this amount between the two doctors according to the period of time that each doctor was responsible for the patient's care. (The actual number of visits to either doctor is irrelevant.)

In our case study, Ms. Ford underwent cataract surgery on August 1. For the first 10 days of the postoperative period, she was under Dr. Dodge's care.

According to the transfer letter, she was discharged to Dr. Kelly on August 11, even though she wasn't going to see him for 3 weeks. That transfer date represents the point at which responsibility for the patient's care shifts from the surgeon to the receiving doctor. (Note the italicized sentence in the sample letter below.) Following the transfer, Dr. Kelly provided care for 80 days, up to the end of the postoperative period.

Because Dr. Dodge was responsible for 10 days of postoperative care and Dr. Kelly was responsible for 80 days, Medicare would pay 10/90ths of the postoperative amount to the surgeon, and 80/90ths to Dr. Kelly.

Individual cases vary, so claims for reimbursement will likewise vary. Consequently, each claim should be treated as unique. (It's important to give every claim extra attention to be sure that the chronology of events matches the dates given.)

Using the right modifiers

Medicare has established specific modifiers to distinguish claims for intraoperative services from claims for postoperative care. The -54 modifier is used to denote the actual surgical event in a co-managed case; the -55 modifier is used with claims for postoperative care.

Immediately after surgery, a claim for the surgical component may be submitted, using the appropriate CPT code with the -54 modifier. Because Medicare assigns 80% of the global fees to the intraoperative service, you should bill 80% of your usual charge. (Billing the entire global fee will only result in a higher write-off.)

Later, submit a separate claim for your portion of the postoperative care. As discussed above, you need to know the date that the optometrist assumed responsibility for the remaining postoperative care (the transfer date).

The receiving doctor will submit a separate claim for his or her portion of the postoperative care. Again, it's imperative that both you and the receiving doctor document the transfer date in your correspondence to make sure that your claims for reimbursement agree.

In our example, using the current national reimbursement of $748, correct billing and reimbursement would be as follows:

�        Dr. Dodge would bill for the surgical component using code 66984-54, dated August 1. The Medicare allowable would be 80% of $748, or $598.

�        Later, Dr. Dodge would bill for his portion of the post-operative care using code 66984-55, listing August 2 through the 11th as the relevant dates. He'd receive 10/90ths of the remaining $150, or $17.

�        Dr. Kelly would bill for his share of the postoperative care using code 66984-55 and listing August 12 through October 30 as the relevant dates. He'd receive 80/90ths of the postoperative fee, or $133.

Playing it safe

The current increasing level of scrutiny and debate regarding co-management shouldn't deter you from co-managing patients following cataract surgery. However, you should consider it a wake-up call. If you don't already have an established protocol for this in your practice, create one now. It's the best kind of insurance.

Next month . . .

You may be sure that you're correctly sharing post-op cataract care with other providers, but what about refractive surgery co-management? We'll tell you what you need to know.

When No Co-Management Agreement Exists

Medicare carriers have outlined regulations for services provided during the postoperative period in the absence of a co-management agreement. If the surgeon bills for the global fee but the patient is seen by a second doctor for services within the postoperative period, carriers are instructed to pay the second doctor separately using the evaluation and management (E/M) codes. The global fee isn't shared as long as this is an unusual, occasional service and doesn't reflect a pattern.

Separate payment isn't made if the second doctor is covering for the surgeon (i.e., locum tenens, or part of the same group as the surgeon).

Sample Transfer Agreement from Dr. Dodge to Dr. Kelly

Dear Dr. Kelly:

On August 1 our patient, Ms. Sally Ford, underwent successful cataract surgery with implantation of an IOL in her right eye. I saw her on August 2; I also saw her today, following surgery, and her best-corrected vision was 20/20 OD, 20/50 OS.

Enclosed please find a copy of her operative report and postoperative instruction sheet. Her recovery from surgery has proceeded smoothly and is expected to continue that way.

At this time, I am discharging her to your care and have asked her to make an appointment to see you in about 3 weeks. Please keep me informed of her progress and contact me if any problems arise. Ms. Ford will need post-cataract glasses before too long; I trust you can assist her.

Sincerely,
Dr. Dodge

Donna McCune is a senior reimbursement consultant with Corcoran Consulting Group. She has 14 years' experience in ophthalmology, including 12 years as an administrator in a busy med/surg ophthalmic practice in Connecticut.