Reimbursements

Category:

Modifiers 54 and 55

Reimbursement Policy: NDRP-GC-005
Topic: General Coding
Effective Date: July 1, 2018

Description:

This policy addresses the indications and limitations of co-management of surgical procedures that carry a 10- or 90-day global period. It also provides guidelines for proper billing and documentation.

Management of a surgical procedure is the primary responsibility of the operating surgeon. Physicians who perform surgery, and furnish all the usual pre- and post-operative work should bill for global surgical care using the proper CPT surgical code(s). Physicians should not bill separately for visits or other services that are included in the global package.

Occasionally, a physician must transfer the care of the patient during the global period. In these instances, modifier 54 and 55 are used to distinguish who is providing care for the patient.

Definitions:

Modifier-54: Surgical Care Only

This modifier is used by the surgeon and when another physician provides preoperative and/or postoperative care. This modifier is appended to the surgical procedure code.

 Modifier-55: Postoperative Management Only

This modifier is used by the physician who provides postoperative care when another physician has done the surgical procedure. This modifier is appended to the surgical procedure code.

The physician receiving the patient must be licensed to manage all aspects of the postoperative care, including the ability to diagnose potential complications that would require another operation.

Policy: 

The Plan will reimburse approved service lines reporting modifier 54 at 80% of the allowance.

The Plan will reimburse approved service lines reporting modifier 55 at 20% of the allowance.

In all instances the transfer of global surgery must be clinically necessary and appropriate. The transfer of surgical care is allowed only to protect the legitimate interest of the member as outlined below under Indications and Limitations.

Indications and Limitations of Coverage

 Co-management is indicated under any of the following circumstances:

  • The operating surgeon is unavailable after surgery and the patient’s post-operative care has to be managed by another
  • The member is unable to travel the distance to the surgeon’s office for post-operative care
  • The patient voluntarily wishes to be followed post-operatively by another
  • The surgery is performed by an itinerant surgeon in a remote area of the
  • The care is provided in a health professional shortage area (HPSA) and the member is unable to travel to the surgeon’s
  • The surgeon practices in a site remote from where the patient recuperates, g. the surgery is performed in a remote area and the surgeon does not return to the area frequently enough to provide the preoperative or postoperative care.
  • A second illness has developed which prevents travel to the operating
  • A surgery is performed at a site that is far away or while the patient is traveling, vacationing or temporarily living in a distant

Limitations

 The transfer of postoperative care is not covered if:

  • The operating surgeon is available and he/she is able to manage other patients postoperatively, unless the patient voluntarily wishes to be followed postoperatively by another provider.
  • The surgeon does follow the patient postoperatively but splits the fee with another provider.
  • Two or more physicians co-manage patients indiscriminately as a matter of policy and not on a case by case basis.
  • A physician demands to manage the postoperative care and indicates he/she will withhold making referrals to surgeons who would not agree to split global surgery payments.
  • A surgeon opts to transfer postoperative management but follows the patient postoperatively as he/she would have done without transferring postoperative care.
  • The transfer is not made in writing.
  • The transfer of care is used as an incentive for obtaining referrals from providers to receive postoperative care reimbursement.
  • The patient has not consented to transfer of care even after being apprised of the medical and/or logistic advisability, or the risks and benefits of transfer of care.

A claim for co-management will be denied if:

  • Any of the circumstances listed in the “Limitations” subsection of this policy
  • The medical record does not support the “Documentation Requirements” section of this

Documentation Submission: 

  1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
  3. The submitted medical record should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
  4. The medical record documentation must support the medical necessity of the services as directed in this policy.
  5. The surgeon should write his/her usual operative The physician providing postoperative care should document appropriate follow-up care notes.
  6. Transfer of Care must be in writing and The record must indicate the exact date on which post-operative care is assumed by the co-managing physician.
  7. Additionally, the medical record must indicate that the patient was appropriately informed of the medical and/or logistic advisability of transfer of care along with any risks or benefits of this arrangement, and that the patient gave consent to this arrangement prior to its inception.
  8. The documentation that the patient was properly informed as described above, must be made available upon request.