Surgical Global Period Modifiers: Modifier 54, 55, and 56 in Global Surgery Billing

To understand these modifiers, it’s essential to first examine the concept of the surgery global period modifiers.

All medical procedures with a global period consist of three parts, which are explained in more detail later in the article:

1. Pre-operative services
2. Intra-operative services
3. Post-operative care

If a physician does not perform all three components, compliant coding requires the use of specific modifiers: modifier 54 (Surgical care only), modifier 55 (Post-operative management only), and the less commonly used modifier 56 (Preoperative care only), as applicable.

The “Global” Concept

The Centers for Medicare & Medicaid Services (CMS) and other insurers ‘bundle’ services typically related to a surgical procedure into a single reimbursement for that procedure. The global surgical package includes all ‘necessary services typically provided’ by a healthcare provider ‘before, during, and after a procedure,’ as defined by CMS. Surgery Global Period Modifiers play a critical role in identifying and billing for specific services within this bundled payment structure, ensuring accurate reimbursement. This global concept applies across various healthcare settings, including inpatient hospitals, outpatient clinics, ambulatory surgical centers, and physician offices.

According to Medicare’s Global Surgery Booklet, the global surgery payment covers the following services:

• Pre-operative visits after the decision is made to proceed with surgery. For major surgeries, this includes visits the day before the surgery; for minor surgeries, it covers visits on the day of surgery.
• Intra-operative services that are essential and customary parts of the procedure.
• Any additional medical or surgical services required during the post-operative period due to complications, which do not require a return to the operating room.
• Follow-up visits related to recovery from surgery during the post-operative period.
• Post-surgical pain management provided by the surgeon.
• Supplies, except those specifically excluded.
• Miscellaneous services, such as dressing changes, local incision care, removal of operative packs, removal of sutures or staples, managing lines, tubes, drains, casts, and splints, inserting, irrigating, and removing urinary catheters, IV lines, nasogastric and rectal tubes, and managing tracheotomy tubes.

However, the global package does not cover visits unrelated to the surgery’s diagnosis, diagnostic tests, critical care services, or post-operative treatments requiring a return to the operating room, among other exclusions specified in the MLN Global Surgery Booklet.

While CMS, private insurers, and the CPT® codebook support the global package concept, there may be variations in what each includes. This article will focus on Medicare’s guidelines, but it is crucial to check with individual payers for their policies.

Billing the Global Package

For procedures with a 10-day or 90-day global period, separate reimbursement values are assigned for the pre-procedure, intra-procedure, and post-procedure components. These values can be found in the Medicare Physician Fee Schedule, where the columns labeled ‘PRE OP,’ ‘POST OP,’ and ‘INTRA OP’ show the percentage of reimbursement for each component (the total of all three columns should equal 1.00). Surgery Global Period Modifiers are essential for accurately reflecting these components, ensuring proper billing and compliance within the global period.

When a healthcare provider performs a surgical procedure, including all pre- and post-operative care, the procedure should be reported using the appropriate CPT® code for the surgery alone. Additional billing for services included in the global package is not permitted.

When different providers perform components of a global surgical procedure, each provider should report only the services they provided, using the appropriate modifier and listing the surgery date as the service date. If post-operative care is transferred, the receiving provider must not bill for any part of the global services until after performing at least one post-operative visit.

Modifiers for Split Care

• • Modifier 54 (Surgical care only): This modifier is used when one physician or healthcare provider performs the surgery, and another provider handles the pre-operative and/or post-operative care. Modifier 54 indicates that the surgeon is transferring all or part of the post-operative care to another physician or provider.
  • Modifier 55 (Post-operative management only): This modifier is used by the physician who assumes responsibility for post-operative care following the surgeon’s procedure. A surgeon cannot report both modifier 54 and modifier 55 for the same procedure. The use of modifier 54 signals that the surgeon has transferred post-operative care to another provider, and the receiving provider bills with modifier 55.
  • Modifier 56 (Preoperative care only): This modifier is used by a surgeon who only provides pre-operative management services.

These “split-care” modifiers—54, 55, and 56—are valid only for surgical procedures with a 10-day or 90-day global period.

Transfer of Care

If the provider performing the surgery does not handle post-operative care, the post-operative care may be billed separately if both the surgeon and the post-operative care provider agree to transfer care.

The surgeon performing the surgery should append modifier 54 to the appropriate CPT® code(s), indicating the transfer of post-operative care to another provider.

The provider who takes over post-operative care should report the same code(s) as the surgeon but with modifier 55 appended, and only after performing at least one post-operative service. The surgery date should be reported as the service date, and the transfer date should also be noted. Written transfer agreements should be kept in the patient’s medical record.

For example, if an emergency department physician reduces a fracture and applies a cast, the patient might later follow up with their family physician. In this case, the ED physician reports the appropriate fracture care code(s) with modifier 54, while the family physician reports the same code(s) with modifier 55.

If no transfer of care occurs, the services provided by another physician may be billed separately or denied depending on the specific circumstances, according to Medicare rules.

When Not to Use Modifiers 54 and 55

CMS permits exceptions to the use of these modifiers in certain situations, including:

• • If no transfer of care occurs, post-discharge services by a physician other than the surgeon should be billed using the appropriate E/M code, with no modifiers.
  • Physicians providing follow-up services for minor procedures performed in emergency departments should use the appropriate E/M code without modifiers.
  • If another physician provides care for underlying conditions or medical complications during the post-operative period, they should report the appropriate E/M code without modifiers. For example, a cardiologist managing cardiovascular issues post-surgery would bill using an E/M code, not modifiers.

In Summary:

When using surgery global period modifiers 54 or 55, it’s critical to coordinate with the physician who provides the other portion of care. Failing to cooperate in this way may result in one provider (usually the one providing post-operative care) missing reimbursement.

Modifiers: The Key to Accurate Medical Claims Processing

Modifiers are essential tools in medical claims processing. They provide vital context to payers, ensuring accurate interpretation and timely reimbursement of healthcare services.

Why are modifiers so important?

• • Clarity and Accuracy: Modifiers help clarify unique circumstances, such as multiple procedures in a single session, partially completed services, or the need for an assistant surgeon.
  • Preventing Denials: Incorrect or missing modifiers can lead to claim denials, delays in payments, and increased administrative burdens.
  • Compliance and Reimbursement: Proper modifier usage ensures adherence to billing regulations and maximizes reimbursement.

How can providers optimize modifier use?

• • Training and Education: Equip staff with in-depth knowledge of coding guidelines and modifier applications.
  • Regular Audits: Conduct frequent audits to identify and correct errors in modifier usage.
  • Technology Leverage: Utilize automated coding tools to streamline the process and minimize human error.

By prioritizing modifier accuracy and compliance, healthcare providers can significantly reduce claim denials, improve revenue cycles, and ultimately enhance patient care.