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Thread: Proper Use of Modifier 56 and 54

  1. #1

    Default Proper Use of Modifier 56 and 54

    AAPC: Back to School
    I work for an orthopaedic group. I had a PCPs office call me yesterday about a patient that they did an H&P on the day before one of my docs did a total knee. We billed 27447 with no modifier. The PCPs office billed 27447 with mod 56. They are telling me we should have billed with a mod 54. Even though they did an H&P, we also managed the patient per-operatively. What is the correct coding for this situation? Should the PCPs office bill and E/M?

  2. #2
    Join Date
    Apr 2007
    Greeley, Colorado


    The PCP should bill an E/M.
    Lisa Bledsoe, CPC, CPMA

  3. #3
    Join Date
    Apr 2007
    Columbia, MO


    The PCP should hve billed the 27447 with a 56 and a 52 if you requested a pre op eval and if you communicated that your physician wanted to perform a surgery preop also. Then you would have a 27447 56 52 and a 27447 54 then when you do the post op you bill the 27447 with the 55. Sorry but that is truely the way to do this especially when the preop is with in the preop global and one day before the surgey qualifies. They will be paid 10% of the global allowable and your physician will have this deducted. If your physician did not request a pre op eval from the PCP then you have a different issue.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Join Date
    Apr 2007


    Can the same physician bill for both mod 54 & 56? I'm not sure if this is even allowed but MD & OD in same practice. Office want to have the MD do the Pre-op and intra-op. OD is to do the Post op. This is for Glaucoma treatment.
    COC-A (9/2016), CPC-A (11/2015), PAHM (2010)
    Coding Configuration Specialist

    15 years health insurance experience: Audit, Claims, Customer Service, Payment Policy, Provider Relations, and Reimbursement

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