Policy Statement
The Centers for Medicare & Medicaid Services (CMS) designate which procedure codes are valid for use with ‘split-care’ modifiers 54, 55, and 56. Our health plan utilizes these CMS designations in determining procedure code/modifier combinations that are valid for our use.
Our health plan follows CMS in reimbursing modifiers 54 and 55 using the percentages listed on the most current CMS National Physician Fee Schedule Relative Value File for pre-op, intraop, and postop portion of the global package. Our health plan may establish percentages for codes that CMS does not include percentages.
The reimbursement for modifier 54 (surgical care) includes the reimbursement for modifier 56 (pre-op), therefore separate reimbursement will not be made for modifier 56. Charges for code with modifier 56 appended will be denied as invalid procedure/modifier combination.
When deemed medically necessary, the performing surgeon may refer a high-risk patient to his/her primary care physician or a specialist for a pre-operative evaluation. The primary care physician or specialist should bill this surgical clearance encounter with the appropriate level of evaluation and management (E&M) code and follow the ICD-10-CM written guidelines in Section IV “Patients receiving pre-operative evaluations only”.
When postop care is being performed/split by different providers, modifier 55 should be appended to the surgical procedure. The provider should report the actual dates he/she relinquishes or assumes follow-up care for the patient. The plan will reimburse the lesser of the charge or the pro-rated fee schedule allowance for modifier 55 based on the number of days of follow-up care being provided.
References
Cross References
Mod 112 - Modifier 78; Unplanned Return to the Operating/Procedure Room By the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period
