Modifiers which give additional information on medical treatments represented by CPT/HCPCS codes, are well known to expert coders in medical billing and coding firms. Modifiers 54, 55, and 56 are “split care” modifiers applicable with surgical operation codes with a global period of 10 or 90 days.
Modifier 54: Only Surgical Care
When one Physician or other competent health care professional performs a surgical procedure and another professional provides preoperative and postoperative management, surgical services are recognized by appending modifier 54 to the standard procedure number.
Modifier 54: ONLY SURGICAL CARE
When one Physician or other competent health care professional conducts a surgical treatment, and another provider provides preoperative and postoperative management, surgical services can be identified by appending modifier 54 to the regular procedure code.
When several providers deliver components of a worldwide surgical operation, each provider must report only the services they did, mark that service with the proper modifier, and include the surgery date as the new date, in compliance with accurate coding requirements. Specify the date care was abandoned or assumed somewhere else on the claim. When postoperative care is transferred to the physician who provides postoperative follow-up treatment may not charge for any part of the global services until after the patient has visited them for the first postoperative visit.
Modifier 54 Directories
- Suppose more than one physician provides a service contained in the global surgical package. The total amount authorized for all physicians may not surpass what would be charged if a single physician delivered all services unless policy positions allow for a larger payment. For example, if the surgeon does only the procedure and another physician provides preoperative and postoperative inpatient care, the resulting combined income may not exceed the worldwide authorized amount.
- Both the surgical care only bill and the postoperative care alone bill would have the exact date of treatment and the same surgical operation code, with the services identified by applying the relevant modifier.
- A version of the signed transfer agreement must be kept in the beneficiary’s medical record by the surgeon and the physician delivering postoperative care. When postoperative care is transferred, the receiving physician cannot bill for any worldwide services until they have performed at least one service.
- In the absence of transitions of care, the services of another physician may be charged extra or rejected for medical necessity, depending on the circumstances of the situation.
- The following modifiers are used when physicians agree on the transitions of care during the global period:
- Modifier 54: solely for surgical care; or Modifier 55: exclusively for postoperative management
- The surgical care only bill and the postoperative care alone account will have the exact date of operation and the same surgical procedure code, with the services identified by applying the relevant modifier.
Invalid Split care modifier combinations
- Modifiers 54, 55, and 56 are not applicable for obstetric care procedures, and information since particular codes are already available to indicate when multiple providers offer antepartum, delivery, and postpartum care.
- Modifiers 54, 55, and 56 do not apply to procedure codes with a zero-day postoperative duration.
- E/M, anesthetic, radiology, laboratory, medicine, or ambulance procedure codes, and any non-surgical HCPCS code, do not accept modifiers 54, 55, or 56.
- Modifiers 54, 55, and 56 are not considered legitimate for the following provider types: assistant surgeons; ambulatory surgical centers; outpatient hospitals; and inpatient hospitals.
- We hope that this article has provided you with all of the knowledge you need to use modifier 54 correctly. If you are still unsure and require assistance with medical billing for your clinic, please contact us. Our expert team of medical billers and coders ensures timely claim filing and expedites the overall process to make sure that medical practices receive the maximum reimbursements in the shortest amount of time.
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