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MA PPO Host - Claim Payment Policy Bulletin

Modifiers for Shared or Split Surgical Services (Modifiers 54, 55, 56)
MA03.017c

Policy

​This policy applies to professional and outpatient facility claims.​

Modifiers 54, 55, and 56, used to indicate split or shared surgical services, are eligible for reimbursement consideration by the Company when all of the following requirements are met:​
  • A prearranged agreement on the transfer of care must be made, documented, and retained 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 ​provided.
  • The surgical procedure carries a 10-day (minor surgery) or 90-day (major surgery) global surgical period as assigned by the Centers for Medicare and Medicaid Services (CMS),
When a procedure code is appropriately reported with modifier 54, 55, or 56, the Company reimburses in accordance with 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 MPFSDB 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

It is inappropriate to report Modifiers 54, 55, and 56 in the following circumstances:​
  • A professional provider or provider in the same provider group 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 surgery 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 pre- and post-payment clinical review, potential denials or retractions for inappropriate use.


BILLING REQUIREMENTS

The Company has established the following requirements for reporting split or shared surgical services:
  • The professional providers or other qualified healthcare providers must use the same procedure code(s) appended with the Modifier 54, 55, or 56 indicating the component of the global surgery package performed.
  • 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.
  • Modifiers 54, 55, and 56 do not apply to assistant at surgery services.
Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

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.

Services appended with modifiers 54, 55, and 56 are subject to multiple surgery reduction guidelines.​

Description

There are circumstances 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 August 24, 2021​.

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 August 24, 2021.

Novitas Solutions, Inc. Global Surgery Modifiers. 11/01/2018. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144547. Accessed August 24, 2021.

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

Coding

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)
ICD - 10 Procedure Code Number(s)
N/A
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 ​Healthcare Common Procedure System (HCPCS) 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

Modifiers

54Surgical Care Only
55Postoperative Management Only
56Preoperative Management Only


Policy History

REVISIONS FROM MA03.017c
10/25/2021This version of the policy becomes effective 10/25/2021. The intent of this policy remains unchanged, but the policy has been updated to clarify the Company's coverage position and coverage criteria.

The following billing requirements section of this policy:
  • ​The professional providers or other qualified healthcare providers must use the same procedure code(s) appended with the Modifier 54, 55, or 56 indicative the component of the global surgery package performed.
  • Modifiers 54, 55, and 56 do not apply to assistant at surgery services.

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.

10/25/2021
10/25/2021
N/A
MA03.017
Claim Payment Policy Bulletin
Medicare Advantage
No
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