Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifiers for Split or Shared Surgical Services (Modifiers 54, 55, and 56)

Policy #:03.00.31e

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

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), which 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):
  • 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.

In addition to the requirements above, the following requirements apply as listed:
  • Modifier 55
    • 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.
    • 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 applies 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 a link to 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.

It is inappropriate to report Modifier 54, 55, or 56 when:
  • An individual provider performs all three components of the global surgical package (ie, pre-, intra-, and postoperative services). The global surgical package must not be divided into and reported by its component parts.
  • 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).

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

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: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and 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 completed.
Guidelines

This policy is consistent with the reporting requirements established by Current Procedural Terminology (CPT) and the Centers for Medicare and Medicaid Services (CMS).

Multiple surgical guidelines may apply to procedure codes that are reported with Modifier 54, 55, or 56.

Description

As defined by the Centers for Medicare and Medicaid Services (CMS) and applied by the Company, reimbursement for surgical procedures includes most preoperative, intraoperative, and postoperative services. Reimbursement for surgical procedures is typically part of a global surgical package. There are times when the global surgical package for surgical services 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 provides 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.

References


Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12 - Physicians/nonphysician practitioners. 40.2: Billing requirements for global surgeries. [CMS Web site]. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network: Global Surgery Fact Sheet; ICN 907166 March 2015 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf.

CPT Professional Edition: Current Procedural Terminology (Current Procedural Terminology, Professional Ed. (Spiral): American Medical Association (AMA); 2016 Edition.

Understanding Modifiers (Optum Learning Series) (Optum Learning: Coding & Reimbursement Educational); 2015 Edition.




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 03.00.31e
11/21/2018This policy has been reissued in accordance with the Company's annual review process.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2016
Version Issued Date: 12/31/2015
Version Reissued Date: 11/26/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.