Modifier 54 (and Modifier 55) Mastery

Modifier 54 (and Modifier 55) Mastery

Modifier 54 can be key when reporting a portion of global care

All medical procedures that include a “global period” are comprised of three parts: pre-operative services, intra-operative services (e.g., performance of the actual surgery/procedure), and post-operative care (related follow-up visits during the 10- or 90-day global period). If a physician does not perform all three parts of the service, compliant coding dictates that you append modifier 54 Surgical care only, modifier 55 Post-operative management only, and modifier 56, as appropriate.

The “Global” Concept

CMS and other payers “bundle” services typically related to a surgical procedure into reimbursement for that procedure. The resulting global surgical package includes all “necessary services normally furnished” by a provider “before, during, and after a procedure,” as defined by the Center for Medicare & Medicaid Service (CMS). The global concept applies in any setting (e.g., inpatient hospital, outpatient hospital, ambulatory surgical center, physician office, etc.).

Medicare includes the following services in the global surgery payment:

  • Pre-operative visits after the decision is made to operate. For major procedures, this includes pre- operative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.
  • Intra-operative services that are normally a usual and necessary part of a surgical procedure
  • All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room
  • Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
  • Post-surgical pain management by the surgeon
  • Supplies, except for those identified as exclusions
  • Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes

Services not part of the global package include visits unrelated to the diagnosis for which the surgical procedure is performed (unless due to complications of the surgery), diagnostic tests and procedure (including diagnostic radiological procedures), critical care services, and post-operative treatments that requires a return to the operating room, among others listed in MLN Global Surgery Booklet.

Although CMS, private payers, and the CPT® codebook all embrace the global package concept, they do not agree on what that package includes. Medicare rules are covered in this article. Confirm the rules for your other payers.

Billing the Global Package

Those procedures with a 10-day or 90-day global period are assigned separate values for pre-procedure, intra-procedure, and post-procedure reimbursement. You can find these valuations in the Medicare Physician Fee Schedule Relative Value File. The columns labeled “PRE OP,” “POST OP,” and “INTRA OP” list the percentage value that Medicare will reimburse for only that portion of the procedure (the total of the three columns is 1.00).

When a healthcare provider performs a surgery, including all usual pre-and post-operative care, they may report that procedure using the appropriate CPT® code for the surgical procedure, only. Do not separately bill for visits or other services included in the global package.

Transfer of Care Cinches Modifier 54

If the provider who performs the surgical procedure, only (e.g., the “intraoperative” portion of the service), and does not furnish the follow-up care, the post-operative care is paid separately if the provider who performed the surgery and the provider who performs the post-op care agree on a transfer of care.

The provider who performed surgical care should append modifier 54 to the appropriate CPT® code(s) to describe the surgery performed. The modifier signals that the surgeon intends to relinquish “all or part of the post-operative care” to another provider, per CMS.

The physician who provides post-operative care should report the same code(s) as the surgeon, but with modifier 55 appended. The physician should not bill until they have provided at least one service. CMS advises, “Report the date of surgery as the date of service and indicate the date that care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.”

For example, an emergency department physician may reduce a fracture and place a cast. Per a transfer of care agreement, the patient later follows-up with their family physician. The ED physician would report the appropriate fracture care code(s) with modifier 54 appended. The family physician would report the same code(s), but with modifier 55 appended.

Per Medicare rules, “Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.”

The Takeaway: When appending modifier 54 or modifier 55, you must coordinate your coding with that of the physician who provides the other portion of care. Failure to cooperate in this way will likely result in one physician (usually the physician who provides postoperative care) missing out on reimbursement.

When Not to Use 54 and 55

CMS allows exceptions to the use of modifiers 54 and 55 for follow-up services during a post-operative period in the following circumstances:

  • Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate E/M code. No modifiers are necessary on the claim.
  • Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier.
  • If the services of a physician, other than the surgeon, are required during a post-operative period for an underlying condition or medical complication, the other physician reports the appropriate E/M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient. For more information, refer to the Medicare Claims Processing Manual, Chapter 12, Sections 40.2 and 40.4.

Medicare Won’t Accept Modifier 56

Orthopaedic Surgery COSC

Modifier 56 Preoperative management onlydescribes a provider’s pre-operative services, only. Medicare does not recognize modifier 56, and instead includes preoperative care in the payment for the intraoperative portion of the service. Guidelines may differ for other payers.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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