Use of Modifiers 54, 55, and 56

Using Modifiers, the service or procedure can be altered by some specific conditions but has not been changed in definition or code. The intention of modifiers is to give more specific information about a specific procedure or service that is not already contained in the code definition itself. MBC is sharing more information on Use of Modifiers 54, 55, and 56 here below.

GLOBAL SURGERY BILLING and CODING Modifiers 54, 55, and 56

Physicians who carry out the surgery and give all of the usual pre- and post-operative care may bill for the global package by entering the appropriate CPT code for the surgical procedure only. Separate billing is not allowed for visits or other services that are included in the global package.

When different physicians in a group practice participate in the care of the patient, the group practice bills for the entire global package if the physicians reassign benefits to the group. The physician who performs the surgery is reported as the performing physician.

Modifier Definitions:

Modifiers 54 : Surgical Care Only

When one physician or other skilled health care qualified performs a surgical procedure and another provider preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.

Modifier 55 : Postoperative Management Only

When one physician or other skilled health care qualified performed postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number.

Modifier 56: Preoperative Management Only

When one physician or other skilled health care qualified performed the preoperative care and evaluation and another performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number

Using Modifiers “-54” and “-55”

Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier.

While doing billing the physician must use the same CPT code for global surgery services billed with modifiers 54 or 55. For surgical care only and post-operative care only, the same date of service and surgical code must be reported. The date of service is the date the surgical procedure was carried out.

Modifier 54 specifies 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 55: does not apply to an Ambulatory Surgical Center (ASC’s) facility fees.

The physician, other than the surgeon, who furnishes post-operative management services, bills with 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 is not appropriate for assistant-at-surgery services or for ASC facility fees.

Exceptions

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 postoperative 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 the underlying cardiovascular conditions of a patient.

For more information, refer to the Medicare Claims Processing Manual

Preoperative Care (modifier code -56)

During the preoperative visit, the surgeon discusses the surgery to be performed, evaluates the patient’s condition and ability to tolerate the planned surgery, prepares the admission documents, and has the patient sign the appropriate consent forms. These services are not customarily delegated to another physician.

In some cases, the patient may have an ongoing physical issue that could carry additional risk during surgery. In such a case, the surgeon might ask the patient to visit a specialist or their internist for surgical clearance. When this occurs, the specialist or internist will bill for the appropriate consultation or office visit and use the patient’s condition as the primary diagnosis.

Inacceptable procedure code/split care modifier combinations:

• Modifiers 54, 55, and 56 (aka split global-care billing) do not apply to procedure codes with a 0-day postoperative period.
• Modifiers 54, 55, and 56 are not considered valid for obstetric care procedure codes, as specific codes already exist to identify when more than one provider provides antepartum, delivery, and postpartum care.
• Modifiers 54, 55, and 56 are not considered valid for provider types to which the global surgery concept and a postoperative care global period do not apply:
  • Assistant surgeons
  • Ambulatory Surgery Centers
  • Outpatient Hospitals
  • Inpatient Hospitals
• Modifiers 54, 55, and 56 are not considered valid for E/M, anesthesia, radiology, laboratory, medicine, or ambulance procedure codes, or any non-surgical HCPCS code.

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