Modifiers 54 and 55, co-management of surgery/post-op care

Modifier 54: Surgical care services only

Priority Health global periods are modeled after Centers for Medicare and Medicaid Services (CMS) global periods.

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 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, don't append this modifier.
  • ER and urgent care providers, review for use with global package CPT codes as it is unlikely that you provided the preoperative and/or postoperative portions. ER claims without modifier 54 will require supporting documentation to show that a global (10 or 90 day) service was provided.

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 date of surgery as the date of service in box 24.
  • To report co-management, see the Cataract surgery page. Report the post-op care days in units in the notes section of the claim, or it may be denied due to insufficient information.
  • 2018 claims and after: Effective for dates of service on or after January 1, 2018 report postoperative days in units (1 day = 1 unit) to reflect the number of days of postoperative care when postoperative care is split between the ophthalmologist and optometrist providers (not to exceed a total of 90 units).
  • Do not use this modifier when there is no global surgical period (10 or 90 days) associated with the CPT code.