Payers Treat Group Practices as 1 Provider

Payers Treat Group Practices as 1 Provider

Medical billing rules can get hazy when dealing with group practices. It is difficult to determine if physicians within a group should bill separately for follow up care if another physician performed the actual surgery. There are rules to follow in this type of situation that make medical billing easier to understand.

When there is a group of physicians in the same practice, usually one does surgery. With surgery there is usually follow up care that is bundled in the CPT code for medical billing. This means that surgeons cannot bill separately for follow up care and for the surgery. This also goes for any other doctor in the practice. If Jane gets a bunionectomy from Dr. Smith, but then goes for follow up care to a Dr. Robinson in the same office, Dr. Robinson will not get paid separately for her visit. That would be like paying Dr Smith AND Dr. Robinson for one follow up visit.

The only time in medical billing where two providers in the same practice can be paid for follow up care is when complications arise. If Jane goes to see Dr Robinson for her follow up care and Dr Robinson sees the stitches have split, he may need to perform surgery to repair. If this is the case, he would do medical billing with a modifier 78. Modifier 78 means to return to the operating room for a related procedure during the postoperative period. This is the only medical billing case in which both Dr .Smith and Dr. Robinson would be treated as if they were separate doctors.

Medical billing is packed with correct procedures and policies group practices must abide by. When a procedure is billed globally with follow up care, usually the surgeon is the only one to get paid for services. In medical billing, payers treat groups as if they were one provider.

View all Articles by: Melissa Clark, CCS-P