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:
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.
- 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),
INAPPROPRIATE CIRCUMSTANCES FOR REPORTING MODIFIERS 54, 55, and 56
- 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.
It is inappropriate to report Modifiers 54, 55, and 56 in the following circumstances:
REQUIRED DOCUMENTATIONThe 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.
- 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).
The Company has established the following requirements for reporting split or shared surgical 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.
- 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.