Using modifiers 54 and 55: Co-management of surgery/post-op care
Modifier 54: Surgical care services only
When a physician performs only surgical services for a member, the appropriate surgical CPT codes should be reported along with modifier 54. Modifier 54 indicates that only the surgical component of the global package will be performed by this provider.
- Report modifier 54 when it is known that post-operative care will be performed by or transferred to another health care provider.
- Do not bill the global surgical code when post-operative care is being provided by another health care provider.
- We review historical data prior to reimbursing claims submitted with modifiers 54 and 55. If an unmodified surgical code is reported and global payment made, claims submitted with a 54 or 55 will be denied as inclusive or redundant to the global surgical payment.
- Use modifier 54 when the CPT code has a global surgical period (10 or 90 days); if there is no global period, this modifier should not be appended.
Modifier 55: Post-operative services only
When a physician provides and/or co-manages post-operative care for a member, report the appropriate surgical CPT code along with modifier 55. Modifier 55 indicates that only post-operative services of the global surgical package were rendered by this provider.
- Reimbursement will be made based on the dates that post-operative care was rendered.
- The post-operative period begins the day after surgery. Enter the first date the member was seen for post-op care as the date of service in box 24.
- Report the date post-op care stopped (an "end" date) in the notes section of the claim, or it may be denied due to insufficient information.
- Do not use this modifier when there is no global surgical period (10 or 90 days) associated with the CPT code.
