Split Surgical Services (Modifiers -54, -55 and -56)
Effective Date: January 4, 2018
Last Updated: August 1, 2021
To provide guidelines for the reimbursement of eligible services where physicians agree on the transfer of care for during preoperative management, surgical care, or postoperative management during the global surgical period.
- NJ FamilyCare/Medicaid
- Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
- Global Surgical Package: Includes all the necessary services normally furnished by a surgeon before, during, and after a procedure. Payment for a surgical procedure includes the preoperative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty.
- Modifier -54: When one (1) physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services are identified by adding modifier -54 to the usual procedure number.
- Modifier -55: Post-Operative management only indicates a physician or other qualified health care professional, other than the surgeon, performed all or part of the outpatient postoperative.
- Modifier -56: Pre-Operative management only indicates a physician or other qualified health care professional, other than the surgeon, performed the preoperative care and evaluation.
When more than one physician performs services that are included in the global surgical package, services will be distinguished by the use of the appropriate modifier:
- Modifier -54- Surgical Care Only
- Modifier -55- Post-Operative Care
- Modifier -56- Pre-Operative Care
Each physician should use the same procedure code with the corresponding modifier representing the part of the global surgical package performed. The date of service for both the surgical care only and post-operative care must be the date the service was rendered. The total amount reimbursed for all physicians involved in the care cannot be higher than what would have been paid if a single physician provided all aspects of the care.
The surgeon and the physician furnishing the post-operative care must keep a copy of the written transfer agreement in the member’s medical record.
Horizon NJ Health will consider for reimbursement for the transfer of care during the Global Surgical Period as followed when modifiers are appropriately appended as identified below:
|-54||Surgical Care Only||75% of the applicable contracted fee schedule|
|-55||Post-Operative Care||15% of the applicable contracted fee schedule|
|-56||Pre-Operative Care||10% of the applicable contracted fee schedule|
Medicare Claims Processing Manual (Pub.100-04). Chapter 12
American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services
Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:
- Benefit Limitations;
- The terms of any applicable provider participation agreement;
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
- Medical necessity; and
- Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.
CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.
|08/01/2021||Combined Policies for Modifier -54, Modifier -55 and Modifier -56.
Updated formatting. Reference for CMS added.