Modifier Codes 54, 55 and 56

HMSA pays for most surgical procedures including preoperative visits, the surgery, and postoperative visits as a "surgical package" or "global fee."

Preoperative Care (modifier code -56)

During the preoperative visit, the surgeon discusses the surgery to be performed, evaluates the patient's condition and ability to tolerate the planned surgery, prepares the admission documents, and has the patient sign the appropriate consent forms. These services are not customarily delegated to another physician. (See Preoperative Visits.)

In some instances, the patient may have an ongoing physical problem that could pose additional risk during surgery. In such a case, the surgeon may send the patient to a specialist or their internist for surgical clearance. When this occurs, the specialist or internist will bill for the appropriate consultation or office visit and use the patient's condition as the primary diagnosis.

Example:

For example, if abdominal surgery is planned for a patient with underlying heart disease, the surgeon may wish to have the patient's cardiologist examine the patient and give the patient a preoperative clearance. In this instance, the surgeon will still do the routine preoperative care and the cardiologist will bill for an established patient office visit. (The cardiologist would not bill the surgical code with modifier 56.)

Postoperative Care (modifier code -55)

During the postoperative period for a major surgery (usually 90 days), the surgeon performs routine postoperative care. (See Postoperative Visits.)

However, there may be times when a surgeon chooses to turn over the postoperative care to the patient's internist. For example, a patient from a Neighbor Island may have surgery on Oahu and receive postoperative care from an internist at home. Because the postoperative care is included in HMSA's payment for the surgical package, the internist should not bill for office visits. The surgeon and the internist should reach an agreement about sharing HMSA's payment for the surgery. The internist will then bill for postoperative care using the surgical procedure code and modifier code 55.

Surgical Care Only (modifier code -54)

If a surgeon has performed the surgery only, the surgeon will bill using the surgical procedure code and modifier code 54. If the surgeon has billed the preoperative care and the surgery, but has turned over the postoperative care to another physician, the surgeon will bill using the surgical procedure and the following modifiers: 54 and 56.

Note: When a physician other than the surgeon performs services that are considered part of the surgical package, the agreed-upon percentage fee splits should appear in Block 19 of the CMS 1500 claim form for both physicians.

Claims Filing Information

When filing claims using one or more of the modifiers listed above, include information about the fee distribution in block 19 of the CMS 1500 claim form or in a comparable field for electronic submission. The two providers must come to an agreement on the fee split.

For example, if a patient's PCP (Dr. A) plans to perform the postoperative care, but the surgeon (Dr. B) did the preoperative care and surgery, claims might be submitted with notes similar to those listed below.

Dr. A's claim would list the CPT code for the surgical service (not an office visit) with modifier 55 indicating that they performed the postoperative care. In block 19, Dr. A may indicate "Fee split agreement - Dr. B = 90%, Dr A = 10%.

Dr. B's claim would list the CPT code for the surgical service followed by modifier codes 54 and 56. In block 19, Dr. B may indicate "Fee split agreement - Dr. A = 10%, Dr. B = 90%.

If such information is not found on the claim, the claim could not be processed for the appropriate payment.

Revision History