Policy No: 107
Originally Created: 03/01/2009
Last Reviewed: 01/01/2019
Last Revised: 01/01/2019
Effective Date: 05/01/2019
This policy applies only to physicians and other qualified health care professionals.
Current Procedural Terminology (CPT®) Modifier 54 Surgical Care Only
When one physician performs a surgical procedure and another provides the preoperative and/or postoperative management, the surgical services are identified by attaching modifier 54 to the surgical procedure code.
CPT Modifier 55 Postoperative Management Only
When one physician performs the postoperative management and another physician performs the surgical procedure, the postoperative component is identified by attaching modifier 55 to the surgical procedure code.
CPT Modifier 56 Preoperative Management Only
When one physician performs the preoperative evaluation and care and another physician performs the surgical procedure, the preoperative component is identified by attaching modifier 56 to the surgical procedure code.
The Centers for Medicare & Medicaid Services (CMS) designate which procedure codes are valid for use with 'split-care' modifiers 54, 55, and 56. Our health plan utilizes these CMS designations in determining procedure code/modifier combinations that are valid for our use.
Our health plan follows CMS in reimbursing modifiers 54 and 55 using the percentages listed on the most current CMS National Physician Fee Schedule Relative Value File for pre op, intra op, and post op portion of the global package. The health plan may establish percentages for codes that CMS does not include percentages.
The reimbursement for modifier 54 (surgical care) includes the reimbursement for modifier 56 (pre-op) therefore separate reimbursement will not be made for modifier 56. Charges for code with modifier 56 appended will be denied as invalid procedure/modifier combination.
When deemed medically necessary, the performing surgeon may refer a high-risk patient to his/her primary care physician or a specialist for a pre-operative evaluation. The primary care physician or specialist should bill this surgical clearance encounter with the appropriate level of Evaluation and Management (E/M) code and follow the ICD-10-CM written guidelines in Section IV "Patients receiving preoperative evaluations only".
When post op care is being performed/split by different providers, modifier 55 should be appended to the surgical procedure. The provider should report the actual dates he/she relinquishes or assumes follow-up care for the patient. The plan will reimburse the lesser of the charge or the pro-rated fee schedule allowance for modifier 55 based on the number of days of follow-up care being provided.
American Medical Association. Appendix A: Modifiers, Current Procedural Terminology (CPT®). AMA Press
CMS National Physician Fee Schedule Relative Value File
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.