Comanagement Made Easy

By: J. Alberto Martinez, MDCarolina Clavijo, Practice Manager

• Regulatory concerns• CMS instructions• Documenting comanagement in the record• Billing guidelines • Is it appropriate to co manage deluxe IOLs or ‐

refractive surgery?

Comanagement Practice management angle

• Value of post op care is ~20% of global package‐– Not all payers agree• Surgeon uses 54 modifier (surgery)• Surgeon does part or no posts op care‐• One or both doctors use 55 modifier• Some payers carve out 56 modifier for pre op ‐

care• Value of 55 postop care is apportioned by DOS‐

Comanagement

Comanagement CMS Instructions• Requires transfer agreement• Written documentation• Proper use of modifiers (54, 55)• Segregation of o post-op care based on responsible

parties • Receiving doctor must see the patient• When no agreement exists, use E/M codes• Group members are ineligible

DocumentationRequired

• Written transfer, patient consent and disclosure

• Transfer date• Available to Medicare upon request

Postoperative Care Request Form• Patient’s consent to co manage‐

-Usually written request, signed• Clinically appropriate• Competency• Provision for complications• Financial statements• Signatures (patient, both doctors)

• On May 1 the patient underwent cataract surgery. The surgeon saw the patient on post op day 1 and 10.

• Effective May 12 (11th post op day), the surgeon released the patient to your care for the remainder of the post op ‐care.

• The patient is not scheduled to see you until May 31 (30 days post-op)

• How many days of o post op care can you bill to Medicare?‐a) 90 daysb) 80 daysc) 60 daysd) 0 days

• How many day of postop care can you bill to Medicare?

b) 80 days

Cataract Comanagement – ONE eyeM.D. CARE O.D. FOLLOW UP‐

0 10 90May 1 May 12 July 30

SURGEON'S CLAIM OPTOMETRIST'S CLAIM5/1 66984 54 ‐5/2 5/11 ‐ 66984 55 ‐ 5/12 7/30 66984 55 ‐ ‐

Refer to surgery DOS

Reimbursement• Postop care is ~20% of global package• Some Claims require“# units”(days) of PO to appear on claims• Value of postop care is apportioned:

– 10/90ths to Surgeon – 80/90ths to Optometrist

Claim Format

“Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.” • Source: MCPM, Ch. 12, 40.2.A.3

Claim Example – Surgeon

Claim Example – Surgeon

Claim Example – Optometrist

ComanagementBilateral Surgery1/05/2012 – Cataract extraction OD1/06/2012 –1 day post op visit OD by surgeon1/12/2012 – 1 week post op visit by surgeon1/19/2012 – Cataract extraction OS 1/20/2012 – 1 day post -op OS / 15 day post-op by surgeon 1/21/2012 – Patient released to Dr. Optometry for both eyes

How many days of post op care does the optometrist bill for?‐a) 90 days for both eyesb) 80 days OD / 89 days OSc) 75 days OD / 89 days OSd) Too confusing to bill

Comanagement

Bilateral Surgery1/05/2012 – Cataract extraction OD1/06/2012 –1 day post op visit OD by surgeon1/12/2012 – 1 week post op visit by surgeon1/19/2012 – Cataract extraction OS 1/20/2012 – 1 day post op OS / 15 day post op OD by surgeon1/21/2012 – Patient released to Dr. Optometry for both eyes

How many days of post op care does the optometrist bill for?‐• c) 75 days OD / 89 days OS

Cataract Co Management – TWO eyes‐

Reimbursement

• Postop care is ~20% of global package • Value of postop care is apportioned:• 15/90ths to Surgeon RT 75/90ths to Optometrist• 1/90ths to Surgeon LT 89/90ths to Optometrist

ComanagementPremium IOLs

• P-IOLs– Presbyopia correcting IOLs‐– Astigmatism correcting IOLs‐

• Potential Risks– Balance billing in violation of assignment – Violations of state anti kickback laws‐– Fee splitting– Medical risks, mismanagement

Do• Assign roles and

responsibilities • Set discrete fees for additional

services rendered that are not part of standard cataract surgery

• Collect separate payment for non covered refractive services performed• Obtain two financial waivers

for non covered services‐

Do not• Extrapolate Medicare’s 80/20 rule to determine value of non covered services• Comingle funds• Fail to provide patient with

clear description of co‐management arrangement

Extended Care PackageTypical Non covered professional services  (excluded)‐

• Corneal topography associated with refractive surgery• Contact lens trial fitting to assess refractive error• Wave front aberration testing to assess refractive error• Corneal pachymetry associated with refractive surgery• Routine eye care, wellness care, preventive care, extended

post operative period • Refractive keratoplasty• LASIK enhancement• IOL exchange

Financial Separation

• Separate charges• Separate checks• Separate credit card charge slip• Separate money orders• Separate promissory notes

ComanagementExample – Financial Separation

For illustration purposes only

Patient Consent

• Patient understands logistics• Disclose financial arrangements• Competency• Authorization to share information • Provision for complications• Signatures (patient, both doctors)

OIG Advisory Opinion: Comanagement

• OIG publishes opinion on co management involving non covered ‐ ‐services associated with premium IOLs

• Tightly worded favorable opinion• Based on the facts …for an advisory opinion … , we conclude that

the Proposed Arrangement would not generate prohibited remuneration under the anti kickback statute. Accordingly, the OIG ‐would not impose administrative sanctions on… under sections … of the Act (as those … relate to the commission of acts described in section … of the Act) in connection with the Proposed Arrangement. This opinion is limited to the Proposed Arrangement and, therefore, we express no opinion about any ancillary agreements or arrangements disclosed or referenced in your request for an advisory opinion or supplemental submissions

• Source: OIG Advisory Opinion No. 11-14

Comanagement P-IOLs Protocol• Surgeon decides suitability for surgery• Physicians and patient discuss post op care ‐

options• Co management depends on what is best for ‐

patient• Justify additional charge(s)• Financial separation

Interested in comanagement? Call us (301) 896-0890 ext 124

or e-mail Carolina@visionaryeyedoctors.com