Modifiers
Modifier 54, 55, 56
When more than one physicians performs the entire surgical package, but not in a group practice, the charges are submitted separately.
Physicians in a group practice should bill for the entire global package if they reassign benefits to the group and all services are performed by two or more physicians within the group.
The physician who performs the surgery is shown as the performing physician.
Reimbursement is reduced because only one portion of the global surgical package is performed. The total of all the service components for preoperative, postoperative, and surgical care is 100% of the global fee. The global surgical package pertains to major surgical procedures (those defined with a postoperative period of between 10 days and 90 days) and consists of preoperative management, surgical care, and postoperative management.
Modifier 54
Surgical Care Only
This modifier is used by a physician or other qualified healthcare provider who performs a surgical procedure and transfers the postoperative management to another provider.
Modifier 55
Postoperative Management Only
This modifier is used by the healthcare provider who only performs postoperative management.
Modifier 56
Preoperative Management Only
This modifier is used by the healthcare provider who only performs preoperative care and does not perform intraoperative (surgical) OR postoperative care.
Split-care modifiers 54, 55, and 56 are only valid when used with surgical procedure codes that have a 10-day or 90-day global period.
Provider Types
Modifiers 54, 55, and 56 are not valid for provider types to which the global surgery concept and postoperative global period do not apply, including:
- Assistant surgeons
- Ambulatory surgery centers
- Outpatient hospitals
- Inpatient hospitals
Obstetric Care
Modifiers 54, 55, and 56 are not valid for obstetric care procedure codes.
Specific procedure codes already exist to identify services provided by multiple practitioners for:
- Antepartum care
- Delivery
- Postpartum care
Procedures With a 0-Day Global Period
Modifiers 54, 55, and 56 do not apply to procedure codes with a 0-day postoperative global period.
Nonsurgical Services
Modifiers 54, 55, and 56 are not valid for:
- Evaluation and management services
- Anesthesia services
- Radiology services
- Laboratory services
- Medicine services
- Ambulance services
- Any other nonsurgical HCPCS codes
Billing for Split Surgical Care
When the surgeon personally provides the entire global surgical package, the services should be submitted as a single claim using:
- The surgical procedure code
- The date of the surgical procedure
This claim includes all postoperative care provided during the applicable global period, such as 10 or 90 days.
When postoperative care is transferred to another provider, both providers submit claims using the same surgical procedure code. The applicable modifier identifies which portion of the global surgical package each provider performed.
Procedure Code – The surgeon and the provider managing postoperative care must report the same surgical procedure code with their respective modifiers appended.
Date of Service – Both claims must use the date of the surgical procedure as the date of service.
Postoperative Visits
Individual postoperative visits should not be reported using evaluation and management codes with modifier 55 appended.
Modifier 55 may only be appended to a surgical procedure code with a 10-day or 90-day global follow-up period.
Valid Split-Care Modifier Combinations – Split-care modifiers 54, 55, and 56 are valid only with surgical procedure codes that have a 10-day or 90-day global period.
Modifier 54Â Surgical Care Only
When 1 (one) physician or other qualified healthcare professional 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 1 (one) physician or other qualified healthcare professional 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 1 (one) physician or other qualified healthcare professional 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.