Description:
This policy provides guidelines for the reimbursement of services with modifiers 54, 55 and 56 for professional providers.
Definitions:
Modifier
| Description
|
| 54 | Surgical Care Only |
| 55 | Postoperative Management Only |
| 56 | Preoperative Management Only |
Policy:
The
global surgical package consists of the preoperative, surgical, and
postoperative services. A split surgical package occurs when the
postoperative care is rendered by a physician other than the physician
performing the surgical service.
Modifier 54 indicates that a
physician or qualified health care professional (QHP) performed a
surgical procedure and transferred the postoperative management to
another provider.
The 55 modifier indicates that a physician or QHP other than the surgeon performed the postoperative care only.
Modifier
56 is used when a physician or QHP performed the preoperative care but
does not provide the intraoperative (surgical) or postoperative
services.
In accordance with National Correct Coding Initiative
(NCCI) Guidelines, it is required that the same surgical procedure code
(with the appropriate modifier) be used by each physician or QHP to
identify the service(s) provided when the components of a global
surgical package are performed by different physicians or QHP(s).
Do not append modifiers 54, 55, or 56 to Assistant Surgeons and/or Ambulatory Surgery Centers (ASC) services.
Split
surgical package situations will be reimbursed not to exceed 100% of
the total global surgical allowable amount, and are reimbursable at the
percentages indicated:
Modifier
| Reimbursement Percentage
|
| 54 | 70% of the fee schedule |
| 55 | 20% of the fee schedule |
| 56 | 10% of the fee schedule |
Note: Effective
October 1, 2019, the 54 modifier will be reimbursed at 70% of the fee
schedule. Any claims with a date of service prior to October 1, 2019,
will be reimbursed at 80% of the fee schedule.
Procedure Codes with Global Periods:
Modifiers
54, 55, and 56 are only valid with surgical procedure codes with a
global period of 10 or 90 days. Procedure codes that have a global
period are developed based on the Center for Medicare & Medicaid
Services (CMS) Physician Fee Schedule (PFS) Relative Value Unit (RVU)
File status indicators. All codes in the PFS RVU File with the status
indicator of “010” or “090” are eligible for reimbursement with the
appropriate modifier appended.
| CMS Definition for Global Periods
|
| 010 | Minor
procedure with preoperative relative values on the day of the procedure
and postoperative relative values during a 10-day postoperative period
included in the fee schedule amount; evaluation and management services
on the day of the procedure and during this 10-day postoperative period
generally not payable. |
| 090 | Major surgery with a 1-day preoperative period and 90-day postoperative period included in the fee schedule payment amount. |
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In
instances where the provider is participating, based on member
benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross-Reference:
CMS PFS RVU File
History:
Date
| Updates
|
| 09/27/19 | Added the 56 Modifier, CMS status indicators, Limitations and Exclusions, Disclaimer and History. |
| 10/01/19 | Reimbursement percentage changed from 80% to 70% for modifier 54 for any dates of service 10/01/19 and after. |
