Q: Can you tell us about the proper use of the 54, 55 and 56 variants?
Answer: To understand these modifications, we first need to review the global duration of surgery. All medical procedures covering the global period are made up of three parts, which are described in more detail later in the article:
- Pre-operative Services
- Operative services, and
- Postoperative care.
If the physician does not perform all three parts of the service, compliant coding dictates that you add a modifier 54 Surgical care onlyConverter 55 Postoperative management onlyAnd the lesser used converter 56 Proactive care onlyAccordingly.
The “global” concept
Centers for Medicare and Medicaid Services (CMS) and other payers “bundle” services are usually associated with surgical procedure for reimbursement of that procedure. The resulting global surgical package includes all “required services” generally provided by the provider “before, during, and after a procedure” as defined by CMS. The global concept applies to any system (eg, inpatient hospital, outpatient hospital, ambulatory surgical center, physician office, etc.).
According to Medicare Global Surgery BookletThe following services are included in the global surgery payment:
- Pre-operative visits After the operational decision is made. For major procedures, this includes pre-operative visits the day after surgery. For smaller procedures, this may include pre-operative visits on the day of surgery.
- Intra-operative services are usually a common and essential part of a surgical procedure
- All additional medical or surgical services required by the surgeon during the postoperative period due to complications requiring no additional trips to the operating room
- Postoperative visits were associated with postoperative recovery
- Postoperative pain management by surgeons
- Supplies, excluding those marked as exclusion
- Various services such as dressing changes, local incision care, removal of the operative pack, skin stitches and staples, streaks, wires, tubes, drains, casts and splints; Insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; And changes and removal of tracheostomy tubes
Services Not at all Part of the global package includes non-surgical diagnostic visits, diagnostic tests and procedures, critical care services and postoperative treatments required to return to the operating room, among others listed in the MLN Global Surgery Booklet. .
Although CMS, private payers and the CPT® codebook all embrace the global package concept, they do not agree with what the package contains. In this article, we cover Medicare rules. Be sure to check with each of your payers for their policies.
Global Package Billing
Those procedures with a 10-day or 90-day global period are assigned separate values for pre-procedure, procedural, and post-procedure reimbursement. You can find these assessments in the Medicare physician fee schedule. Columns labeled “PRE OP,” “POST OP,” and “INTRA OP” list the percentage value for reimbursement for that part of the Medicare procedure (total of three columns 1.00).
When health care providers perform surgery, including all general pre- and post-operative care, they can report that procedure using the appropriate CPT® code. Do not bill separately for visits or other services included in the global package.
When various providers provide global surgical procedures, each provider only reports the service they performed and identifies that service with the appropriate modifier and the date of surgery listed as the service date. Elsewhere in the claim that date care has been abandoned or inferred. When a postoperative care transfer occurs, the recipient physician who provides post-operative care should not bill any part of the global services until he / she sees the patient for the first postoperative visit / service.
The variation is 54 surgical care only: When a physician or other qualified health care provider (QHCP) performs a surgical procedure and another provider performs pre-operative and / or postoperative care, surgical services can be identified by adding a modifier 54 to the general procedure code. Modification 54 indicates that the surgeon is giving up all or part of the postoperative care to a different physician or QHCP.
Modification 55 is postoperative management only: This modifier is billed by the receiving physician rather than the surgeon, who receives transfers of care and provides post-operative care services.
The surgeon should not report both modifier 54 and modifier 55 for the same surgical procedure. The use of Modification 54 implies that surgeons have transferred post-operative care (in part or total) to another provider and are billed by providers who accept the surgical code that includes Modification 55.
Converter 56 is pre-operative care only: This modifier is billed by surgeons, who only perform pre-operative services.
‘Split-care’ modifications are only valid with surgical procedure codes of 54, 55 and 56 10- or 90-day global durations.
Transfer of care
Only providers who perform the surgical procedure (for example, the “intraoperative” part of the service) and do not provide follow-up care, pay for post-operative care separately, and providers who perform post-operative care accept the transfer of care.
Providers who have performed surgical care should include a modifier 54 to the appropriate CPT® code (s) to describe the surgery. For each CMS, the signals that the surgeons wish to transfer “all or part of the postoperative care” to another provider.
A physician providing postoperative care should report the same code (s) as the surgeon, but must include a modifier 55. Do not bill until the doctor provides at least one service. CMS advises, “Report the date of surgery as a date of service and specify the date the care was abandoned or presumed. Doctors must keep copies of a written transfer agreement on the beneficiary’s medical record.
For example, an emergency department physician can reduce the fracture and place the cast. For transfer of care contract, the patient will then follow up with their family doctor. The ED physician reports the modification of the appropriate fracture care code (s) with the attachment 54. Family physicians report the same code (s), but modifying 55 is included.
Under the Medicare rules, “if a transfer of care does not occur, the services of another physician may be paid or denied separately for reasons of medical necessity, depending on the circumstances of the case.”
In summary:When adding Modification 54 or Modification 55, you should combine your coding with the physician who provides the other side of care. Failure to cooperate in this way will result in a physician (usually a physician providing post-operative care) forfeiting reimbursement.
54 and 55 should never be used
CMS allows exceptions to the use of Modifications 54 and 55 for follow-up services in the following cases:
If a transfer of care does not occur, the physician’s occasional post-discharge services other than the surgeon are reported through the appropriate E / M code. No modification is required in the claim.
Doctors who provide follow-up services to minor procedures performed in emergency departments bill the appropriate level of E / M code without modification.
If the underlying condition or medical complications during the postoperative period require the services of physicians other than surgeons, other physicians will report the appropriate E / M code. No modification is required in the claim. An example is a cardiologist who manages the patient’s underlying cardiovascular conditions. For more information, see the Medicare Claims Processing Manual, Chapter 12, Sections 40.2 and 40.4.
Renee Dowling is a compliance auditor for Sansum Clinic, LLC in Santa Barbara, California.