Modifiers, which provide additional information on medical treatments indicated by CPT/HCPCS codes, are well known to professional 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.
The ‘Global’ concept
- To understand the complexities of modifiers 54, 55, and 56, you must first comprehend terms related to global surgical care, such as the ‘global surgical package’ and the ‘global period.’
- Preoperative, intra-operative, and postoperative services bundled in a given CPT®/HCPCS Level II code are a global surgical package (or global surgery).
- The number of weeks included in the payments for a global surgical package is referred to as the global period.
Modifier 54: Only Surgical Care
When one physician conducts a surgical procedure while another handles the preoperative and postoperative care, the surgical services are indicated by appending modifier 54 to the medical procedure code.
- Modifier 54 denotes that the surgeon is handing over all or part of the postoperative treatment to a physician.
- Modifier 54 does not include applicable to services provided by an assistant-at-surgery.
- Modifier 54 does not relate to facility costs at an Ambulatory Surgical Center (ASC).
CPT Modifier 55: Only Postoperative Management
When one physician provides postoperative care while another conducts the surgical procedure, the postoperative component is identified by appending modifier 55 to the surgical procedure code.
CMS specifies the following reporting rules for modifier 55:
- For global periods of 10 or 90 days, use modifier “55” with the CPT procedure code.
- List the surgery date as the appointment, and note when care was abandoned or assumed.
- A copy of the signed transfer agreement must be kept in the beneficiary’s medical record by the physician.
- Before invoicing for any part of the postoperative care, the attending physician must give at least one session.
CMS further specifies when modifiers 54 and 55 should be avoided:
- When there is no transfer of care to report infrequent post-discharge services provided by a physician other than the surgeon, the correct E/M code should be used, and no modifiers should be applied.
- Physicians who can provide follow-up care for minor procedures performed in emergency departments bill the appropriate E/M code level without the need for a modifier.
- Suppose a physician other than the surgeon is necessary to provide services throughout the postoperative period for an underlying medical condition or medical complication. In that case, this physician must submit the appropriate /M code. There are no necessary modifiers.
Modifier 56: Only Preoperative Management
When one physician provides preoperative evaluation and care while another conducts the surgical procedure, the preoperative component is recognized by appending modifier 56 to the surgical procedure code.
Modifier 56 Example
If abdominal surgery is scheduled for a patient with chronic heart disease, the surgeon may request that the patient’s cardiologist examine the patient and provide preoperative clearance. In this case, the surgeon will continue to provide standard preoperative treatment while the cardiologist bills for an existing patient office visit. It should note that the cardiologist would not charge the surgical code with modifier 56.
Reliable coders at medical coding outsourcing firms will attach these split care modifiers to claims in collaboration with the physician who performs post-acute care management services. We hope that this article has provided you with all of the knowledge you need to use modifier 54,55, and 56 correctly. If you are still unsure and require assistance with medical billing for your clinic, please contact us. We have a skilled billing and coding team that employs precise modifiers to ensure correct insurance reimbursement.
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