Modifier 55 Fact Sheet

Definition: Modifier 55 –  Postoperative Management Only

• Indicate a physician, other than the surgeon, is billing for part of the outpatient postoperative care.
• Also, used by the surgeon when providing only a portion of the post-discharge post-operative care.

Postoperative Management Only. When a physician or other qualified health care professional performs the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by appending a modifier 55 to the surgical procedure.


Instructions

Modifier 55 is used when the surgeon is either relinquishing all or part of the postoperative days to another physician.


Correct Use

    Surgeon performs part of postoperative care
        Submit claim with two lines using same date of service and procedure code;  append modifier 55 to line 2
        Include date span in Item 19 narrative of CMS-1500 claim form or electronic equivalent
        Submit claim with number of units as 1
    Physician rendering additional postoperative care
        Submit claim with surgery date and procedure code
        Include date span of assumed care in Item 19 narrative of CMS-1500 claim form or electronic equivalent
        Submit claim with number of units as 1

Incorrect Use

    Do not append modifier 55 when surgeon performs surgery only: no postoperative care
        See instructions on modifier 54
    Do not append modifier 55 if patient is under surgeon’s care for full 10 or 90 days of postoperative care
    Do not append on ASC facility or assistant surgeons claims

Claim Coding Example

An orthopedic surgeon performs an open tibial shaft fracture (27759) and bills the surgery with modifier 54. The partial postoperative care (modifier 55) is provided by the surgeon for the initial 45 days (March 10 – April 23) and is then turned over to another physician for the remailing 45 days (April 24 – June 7).

Dr Smith (Surgeon)

Date Treatment Description CPT/Modifier Units
3/9/2016 Open tibial shaft fracture 27759 54 1
3/9/2016 Open tibial shaft fracture 27759 55 1

Appropriate Usage:

• Billed for the surgeon and the physician, other than the surgeon, who furnished a portion of the outpatient postoperative care
• Append to the procedure code that describes the surgical procedure performed that has a 10 or 90-day postoperative period.
• The claim must show the date of surgery as the date of service.
• Indicate the date of care assumption and relinquished in Item 19 of the CMS-1500 claim form or the electronic equivalent.
• After the physician has seen that patient, submit a bill for the period beginning with the date on which they assumed care.
• When two different physicians share in the postoperative care, each bills for their portion-reporting modifier 55 and indicating the assumed and relinquished dates on the claim.

Inappropriate Usage:

• Appending to a surgical code without 10 or 90-day post-op period
• Appending to an E/M procedure code
• Appending to assistant at surgery services
• Appending to Ambulatory Surgical Center’s facility fees
• When the transfer of care occurs immediately after surgery with inpatient care provided, the receiving physician should bill subsequent hospital care codes. Payment will be allowed if they are not the same physician.*
• Do not report modifier 52 along with modifier 55 when furnishing only part of the postoperative care (MN providers only).

Facts

• The physician furnishing postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record.
• Medicare payment is limited to the same total amount as would have been paid if one physician provided all of the care, regardless of the number of physicians providing care.

Using Modifiers “-54” and “-55”

Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier:

• Surgical care only (modifier “-54”); or

• Post-operative management only (modifier “-55”).

The physician must use the same CPT code for global surgery services billed with modifiers “-54” or “-55.” The same date of service and surgical procedure code should be reported on the bill for the surgical care only and post-operative care only. The date of service is the date the surgical procedure was furnished.

Modifier “-54” indicates that the surgeon is relinquishing all or part of the post-operative care to a physician.

• Modifier “-54” does not apply to assistant-at surgery services.

• Modifier “-54” does not apply to an Ambulatory Surgical Center (ASC’s) facility fees.

The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.”

• Use modifier “-55” with the CPT procedure code for global periods of 10 or 90 days.

• Report the date of surgery as the date of service and indicate the date care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.

• The receiving physician must provide at least one service before billing for any part of the postoperative care.

• This modifier is not appropriate for assistant-at surgery services or for ASC’s facility fees.





My claim for post-operative services billed with modifier 55 was rejected, what information was missing?


Answer: 
Failure to submit one or more of the following requirements can result in the rejection of services billed with CPT modifier 55.

CMS-1500 (02/12) Paper Claims

Enter the total number of post-op days in either item 24G or in item 19
Enter the date(s) the post-op care was assumed and/or relinquished in item 19
Enter the date the surgical procedure was performed as the date of service  
Electronic claims – ASC 837 v5010 Loop, Segment, Element

Enter the total number of post-operative days in either the:
Days or units field, Loop 2400, SV1, 04 (03=UN)
Narrative Loop 2300 or 2400, NTE, 02
Enter the date(s) the post-op care was assumed and/or relinquished in either:
Loop 2300, DTP/90, or 91, 03
Narrative Loop 2300 or 2400, NTE, 02
Enter the date the surgical procedure was performed as the date of service
As a reminder, claims that are rejected with remittance message MA130 should be corrected and resubmitted as new claims.  Rejected claims do not have appeal rights. Reopening and redeterminatation requests received for rejected claims will be dismissed.  

Global Surgery

Coverage of any service is determined by a member’s eligibility, benefit limits for the service or services rendered and the application of the Plan’s Medical Policy. Final payment is subject to the application of claims adjudication edits common to the industry and the Plan’s professional services claims coding policies. Reimbursement is restricted to the provider’s scope of practice as well as the fee schedule applicable to that provider.

Purpose To define when the Plan recognizes services appended with Modifier 54, 55 or 56.

Scope Applies to all Company lines of business and products with the exception of Medicare Advantage.

Policy The Plan recognizes Modifiers 54, 55, and 56 appended to a service to indicate when a physician furnishes only part of a global surgical package and relinquishes the other portion(s) of the surgical package to another physician belonging to a different practice.

These modifiers are applicable to codes in the current National Physician Fee Schedule (NPFS) that include global periods of 10 or 90 days. These modifiers do not apply to assistant surgeon services:

* Modifier 54 – Surgical Care Only

o Used to indicate when one physician or other qualified healthcare professional performs the surgical care only and another physician performs the pre-operative or post-operative care, each belonging to a different practice.

o Reimbursement will be 70% of the provider’s applicable Fee Schedule allowed amount.

* Modifier 55 – Postoperative Management Only

o Used to indicate when one physician or other qualified healthcare professional performs the post-operative management only and another physician performs the surgical care, each belonging to a different practice.

o Reimbursement will be 20% of the provider’s applicable Fee Schedule allowed amount.

* Modifier 56 – Preoperative Management Only

o Used to indicate when one physician or other qualified healthcare professional performs the pre-operative management only and another physician performs the surgical care, each belonging to a different practice.

o Reimbursement will be 10% of the provider’s applicable Fee Schedule allowed amount.