Learn the Nuances of Using Modifiers 54, 55 and 56

by | Published on Nov 2, 2018 | Medical Coding

Learn Nuances Using Modifier54
Share this:

Expert coders in medical billing and coding companies are well aware of the significance of modifiers which provide additional information about medical procedures represented by CPT/HCPCS codes. Modifiers 54, 55 and 56 are “split care” modifiers that are valid with surgical procedure codes having a 10- or 90-day global period.

The ‘Global’ Concept

To learn the nuances of using modifiers 54, 55 and 56, it is necessary to understand terms related to global surgical care such as the ‘global surgical package’ and the ‘global period’.

  • Global surgical package (or global surgery) refers to pre-operative, intra-operative, and post-operative services included in a specific CPT®/HCPCS Level II code.
  • Global period refers to the number of days included in the payment for a global surgical package.

The global concept applies to settings such as: inpatient hospital, outpatient hospital, ambulatory surgical center, physician office, etc. Medicare includes the following services in the global surgery payment when provided in addition to the surgery:

  • Pre-operative visits after the decision is made to operate. For major procedures, this includes preoperative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery
  • Intra-operative services that are normally a usual and necessary part of a surgical procedure
  • All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room
  • Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
  • Post-surgical pain management by the surgeon
  • Supplies, except for those identified as exclusions
  • Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes

Billing the global package: Physicians who perform the surgery as well as provide all of the usual pre- and post-operative care can bill for the global package using the appropriate CPT code for the surgical procedure only. Visits or other services that are included in the global package cannot be billed separately.

Use Modifiers 54 and 55 to Indicate Transfer of Care

More than one physician may provide the services included in the global surgical package. When physicians agree on the transfer of care, the follow-up care may be furnished by a provider other than the physician who performs the surgical procedure. Modifiers 54 and 55 should be used when physicians agree on the transfer of care during the global period. The physician should use the same CPT code for global surgery services billed with modifiers 54 or 55. The same date of service and surgical procedure code should be reported on the bill for the surgical care only and post-operative care only.

Modifier 54 – To identify surgical care only: When one physician performs a surgical procedure and another furnishes the preoperative and/or postoperative management, modifier 54 should be added to the usual CPT code to identify surgical services. Per CMS:

  • Modifier 54 indicates that the surgeon is relinquishing all or part of the post-operative care to a physician.
  • Modifier 54 does not apply to assistant-at-surgery services.
  • Modifier 54 does not apply to an Ambulatory Surgical Center (ASC’s) facility fees

Modifier 55 – To identify post operative management services only: When one physician provides the post operative services and another physician has performed the surgical procedure, the physician who provides post-operative care should report the same code(s) as the surgeon, but with modifier 55 appended.

CMS provides the following guidelines for reporting modifier 55:

  • Use modifier “55” with the CPT procedure code for global periods of 10- or 90-days.
  • Report the date of surgery as the date of service and indicate the date that care was relinquished or assumed.
  • Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.
  • The receiving physician must provide at least one service before billing for any part of the postoperative care.
  • This modifier should not be used for assistant-at-surgery services or for ASC facility fees.

Exceptions to the Use of Modifiers 54 and 55

CMS also indicates when modifiers 54 and 55 should not be used:

  • Where a transfer of care does not occur. The appropriate E/M code should be used to report occasional post-discharge services of a physician other than the surgeon and no modifiers need to be appended.
  • Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier.
  • If the services of a physician, other than the surgeon, are required during a post-operative period for an underlying condition or medical complication, this physician has to report the appropriate //M code. No modifiers are required.

Modifier 56, Preoperative Management Services only

When one physician performed the preoperative care and evaluation and another physician performed the surgical procedure, the preoperative component may be identified by adding the modifier- 56 to the usual procedure number.

Medicare does not recognize modifier 56. Only the E/M code should be reported to indicate preop care and evaluation on claims submitted to Medicare. Payers may differ with respect to the rules on the use of modifier 56.

Reliable coders in medical coding outsourcing companies will append these split care modifiers to claims in coordination with the physician who provides postop management services. As an AAPC report notes, lack of such coordination will result in the provider missing out on reimbursement.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

More from This Author