Understand the proper use of modifiers 54, 55 and 56.
Question: Can you tell us the proper use of modifiers 54, 55 and 56?
Answer: To understand these modifiers, we first need to review the surgery global period.All medical procedures that include a global period are made up of three parts, explained in more detail later in the article:
If a physician does not perform all three parts of the service, compliant coding dictates that you append modifier 54 Surgical care only, modifier 55 Post-operative management only, and the less-used modifier 56 Preoperative care only, as appropriate.
The Centers for Medicare & Medicaid Services (CMS) and other payers “bundle” services typically related to a surgical procedure into reimbursement for that procedure. The resulting global surgical package includes all “necessary services normally furnished” by a provider “before, during, and after a procedure,” as defined by CMS. The global concept applies in any setting (e.g., inpatient hospital, outpatient hospital, ambulatory surgical center, physician office, etc.).
According to Medicare’s Global Surgery Booklet, the following services are included in the global surgery payment:
Services not part of the global package include visits unrelated to the diagnosis for which the surgical procedure is performed, diagnostic tests and procedures, critical care services, and post-operative treatments that require a return to the operating room, among others listed in MLN Global Surgery Booklet.
Although CMS, private payers, and the CPT® codebook all embrace the global package concept, they do not agree on what that package includes.In this article, we will cover Medicare rules. Be sure to check with each of your payers for their policies.
Those procedures with a 10-day or 90-day global period are assigned separate values for pre-procedure, intra-procedure, and post-procedure reimbursement. You can find these valuations in the Medicare Physician Fee Schedule . The columns labeled “PRE OP,” “POST OP,” and “INTRA OP” list the percentage value that Medicare will reimburse for only that portion of the procedure (the total of the three columns is 1.00).
When a healthcare provider performs a surgery, including all usual pre-and post-operative care, they may report that procedure using the appropriate CPT® code for the surgical procedure, only. Do not separately bill for visits or other services included in the global package.
When components of a global surgical procedure are furnished by different providers, each provider is expected to report only the service they performed and identify that service with the appropriate modifier and with the surgery date listed as the date of service. Indicate elsewhere on the claim the date care was relinquished or assumed. Where a transfer of postoperative care occurs, the receiving physician providing the postoperative follow-up care may not bill for any part of the global services until after he/she has seen the patient for the first postoperative visit/service.
Modifier 54 Surgical care only: When one physician or other qualified health care provider (QHCP) performs a surgical procedure and another provider performs the pre-operative and/or post-operative management, surgical services may be identified by adding modifier 54 to the usual procedure code.Modifier 54 indicates that the surgeon is relinquishing all, or part, of the post-operative care to another physician or QHCP.
Modifier 55 Post-operative management only: This modifier is billed by the receiving physician, other than the surgeon, who accepts the transfer of care and furnishes post-operative management services.
A surgeon may not report both modifier 54 and modifier 55 for the same surgical procedure. The use of modifier 54 indicates the surgeon has transferred postoperative care (partial or total) to another provider, and the surgical code with modifier 55 appended will be billed by the receiving provider to whom the postoperative care was transferred.
Modifier 56 Preoperative care only: This modifier is billed by the surgeon who only performs the pre-operative management services.
‘Split-care’ modifiers 54, 55, and 56 are only valid with surgical procedure codes having a 10- or 90-day global period.
If the provider who performs the surgical procedure, only (e.g., the “intraoperative” portion of the service), and does not furnish the follow-up care, the post-operative care is paid separately if the provider who performed the surgery and the provider who performs the post-op care agree on a transfer of care.
The provider who performed surgical care should append modifier 54 to the appropriate CPT® code(s) to describe the surgery performed. Per CMS, the modifier signals that the surgeon intends to transfer “all or part of the post-operative care” to another provider.
The physician who provides post-operative care should report the same code(s) as the surgeon, but with modifier 55 appended. The physician should not bill until they have provided at least one service. CMS advises, “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.”
For example, an emergency department physician may reduce a fracture and place a cast. Per a transfer of care agreement, the patient later follows-up with their family physician. The ED physician would report the appropriate fracture care code(s) with modifier 54 appended. The family physician would report the same code(s), but with modifier 55 appended.
Per Medicare rules, “Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.”
In summary:When appending modifier 54 or modifier 55, you must coordinate your coding with that of the physician who provides the other portion of care. Failure to cooperate in this way will likely result in one physician (usually the physician who provides postoperative care) missing out on reimbursement.
CMS allows exceptions to the use of modifiers 54 and 55 for follow-up services during a post-operative period in the following circumstances:
Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate E/M code. No modifiers are necessary on the claim.
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, the other physician reports the appropriate E/M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient. For more information, refer to the Medicare Claims Processing Manual, Chapter 12, Sections 40.2 and 40.4.
Renee Dowling is a compliance auditor for Sansum Clinic, LLC, in Santa Barbara, California.