Reimbursements

Category:

Modifiers 54, 55 & 56

Reimbursement Policy: NDRP-GC-005
Topic: General Coding
Effective Date: July 1, 2018
Last Reviewed Date:
September 27, 2019

Description:

This policy provides guidelines for the reimbursement of services with modifiers 54, 55 and 56 for professional providers.

 

Definitions:

Modifier
Description
54 Surgical Care Only
55 Postoperative Management Only
56 Preoperative Management Only

 

Policy: 

The global surgical package consists of the preoperative, surgical, and postoperative services. A split surgical package occurs when the postoperative care is rendered by a physician other than the physician performing the surgical service.

Modifier 54 indicates that a physician or qualified health care professional (QHP) performed a surgical procedure and transferred the postoperative management to another provider.

The 55 modifier indicates that a physician or QHP other than the surgeon performed the postoperative care only.

Modifier 56 is used when a physician or QHP performed the preoperative care but does not provide the intraoperative (surgical) or postoperative services.

In accordance with National Correct Coding Initiative (NCCI) Guidelines, it is required that the same surgical procedure code (with the appropriate modifier) be used by each physician or QHP to identify the service(s) provided when the components of a global surgical package are performed by different physicians or QHP(s).

Do not append modifiers 54, 55, or 56 to Assistant Surgeons and/or Ambulatory Surgery Centers (ASC) services.

Split surgical package situations will be reimbursed not to exceed 100% of the total global surgical allowable amount, and are reimbursable at the percentages indicated:

Modifier
Reimbursement Percentage
54 70% of the fee schedule
55 20% of the fee schedule
56 10% of the fee schedule

Note: Effective October 1, 2019, the 54 modifier will be reimbursed at 70% of the fee schedule. Any claims with a date of service prior to October 1, 2019, will be reimbursed at 80% of the fee schedule.

Procedure Codes with Global Periods:

Modifiers 54, 55, and 56 are only valid with surgical procedure codes with a global period of 10 or 90 days. Procedure codes that have a global period are developed based on the Center for Medicare & Medicaid Services (CMS) Physician Fee Schedule (PFS) Relative Value Unit (RVU) File status indicators. All codes in the PFS RVU File with the status indicator of “010” or “090” are eligible for reimbursement with the appropriate modifier appended.

CMS Definition for Global Periods
010 Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10-day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during this 10-day postoperative period generally not payable.
090 Major surgery with a 1-day preoperative period and 90-day postoperative period included in the fee schedule payment amount.

 

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

 

Cross-Reference:

CMS PFS RVU File

 

History:

Date
Updates
09/27/19 Added the 56 Modifier, CMS status indicators, Limitations and Exclusions, Disclaimer and History.
10/01/19 Reimbursement percentage changed from 80% to 70% for modifier 54 for any dates of service 10/01/19 and after.

 

 


Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.