Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Modifiers for Shared or Split Surgical Services (Modifiers 54, 55, 56)
Policy #:MA03.017b

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

The Company has established the following requirements for the appropriate reporting of Modifiers 54 (surgical care only), 55 (postoperative management only), and 56 (preoperative management only):
  • A prearranged agreement on the transfer of care must be made by the professional providers who share the global surgical package.
  • The date(s) of service must correspond to the date(s) the specific care was initiated.
These modifiers must carry a 10-day (minor surgery) or 90-day (major surgery) global surgical period as assigned by the Centers for Medicare and Medicaid Services (CMS).

In addition to the requirements above, the following requirements apply as listed:
  • When a provider assumes postoperative care, modifier 55 is appended to the surgical procedure code and reported only after the first postoperative visit is provided.
  • For Modifier 55, the date of the surgery and the date of the follow-up care must be reported on the claim form or electronic equivalent.
  • Modifier 56 should only be reported with the surgical procedure code if a preoperative service is actually performed.

When a procedure code is appropriately reported with modifier 54, 55, or 56, the Company reimburses the Medicare Physician Fee Schedule Data Base (MPFSDB) assigned percentage for the component (preoperative, intraoperative [surgical care], postoperative) performed and reported by a professional provider.
  • Refer to the Coding Table in this policy for direction on how to access Medicare's Physician Fee Schedule Search page to obtain the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes and the applicable global surgical component percentages.

INAPPROPRIATE CIRCUMSTANCES FOR REPORTING MODIFIERS 54, 55, and 56

The following are inappropriate circumstances for appending modifier 54, 55, or 56:
  • An individual provider performs all three components of the global surgical package (i.e., pre-, intra-, and postoperative services).
  • The surgical procedure code does not carry a 10-day (minor surgery) or 90-day (major surgery) global surgical period as assigned by the Centers for Medicare and Medicaid Services (CMS).

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, and therapies, as well as test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Claims submitted with modifier 54, 55, or 56 are subject to post-payment clinical review, and potential retractions for inappropriate use may be effectuated.

BILLING REQUIREMENTS

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
Policy Guidelines

This policy is consistent with Medicare's reporting requirements as well as the reporting requirements established by Current Procedural Terminology (CPT) and the Centers for Medicare and Medicaid Services (CMS). The Company's payment methodology may differ from Medicare.

Description

There are times when the global surgical package for surgical procedures that carry a 10-day or 90-day global period is split or shared between providers. The following modifiers are used in such cases:

  • Modifier 54 represents the surgical care component of a global surgical package. It is reported by the surgeon when another professional provider delivers preoperative and/or postoperative care.
  • Modifier 55 represents the postoperative management component of a global surgical package when performed by a professional provider other than the surgeon.
  • Modifier 56 represents the preoperative evaluation component of a global surgical package when performed by a professional provider other than the surgeon.
As defined by the Centers for Medicare & Medicaid Services (CMS) and applied by the Company, reimbursement for a surgical procedure includes a standard global surgical package, which includes preoperative, intraoperative, and postoperative services.
References


Centers for Medicare & Medicaid Services. Global Surgery Booklet. MLN Booklet. [CMS Web site]. September 2018. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf. Accessed October 9, 2019.

Novitas Solutions, Inc. Post-Operative Co-Management, Modifier 54 and 55. 08/27/19. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00101754. Accessed October 17, 2019.

Novitas Solutions, Inc. Global Surgery Modifiers. 11/01/2018. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144547. Accessed October 9, 2019.

Optum360. Understanding Modifiers 2019. West Salt Lake City, UT: Optum360; 2018.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes within the Intra Op (Modifier 54), Post-Op (Modifier 55), or Pre-Op (Modifier 56) column: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes within the Intra Op (Modifier 54), Post-Op (Modifier 55), or Pre-Op (Modifier 56) column: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html


Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)



Revenue Code Number(s)

N/A


Misc Code

Modifiers:


54: Surgical care only
55: Postoperative management only
56: Preoperative management only



Coding and Billing Requirements






Policy History

REVISIONS FROM MA03.017b
12/16/2019This version of the policy becomes effective 12/16/2019. It reaffirms the Company's continued position on reporting of Modifiers for Split or Shared Surgical Services (Modifiers 54, 55, and 56).

REVISIONS FROM MA03.017a
11/21/2018This policy has been reissued in accordance with the Company's annual review process.
01/01/2016This version of the policy will become effective 01/01/2016. Revised policy number MA03.017a was issued as a result of annual policy review.

REVISIONS FROM MA03.017
01/01/2015This is a new policy.






Version Effective Date: 12/16/2019
Version Issued Date: 12/16/2019
Version Reissued Date: N/A