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Modifier -54 Surgical Care Only - Usage and Reimbursement


Modifier -54 identifies when one physician performs a surgical procedure and another provides preoperative and/or postoperative management. The surgeon who performs the surgical procedure reports Modifier -54.


Submit modifier 54 only with the surgical procedure code.

Do not submit modifier 54 on CPT codes that has 0 days Global period. For example CPT 45378 (
Colonoscopy; diagnostic)

Do not submit modifier 54 on E & M services.

Do not submit modifier 54 along with other Global Surgical split billing modifiers 55 and 56.

Do not submit modifier 54 along with modifiers 80 (Assistant Surgeon), 81 (Minimum Assistant Surgeon), 82 (Assistant Surgeon when qualified resident surgeon not available) and AS (Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant-at-surgery, non-team member)

Reimbursement:

Payment is limited to the amount allotted to the preoperative and intraoperative services only. Medicare has split global surgery package relative values into preoperative, intraoperative, and postoperative percentages. For example the CPT for Total Knee Replacement 27447 has a Global period of 90 days and a field in Medicare physician fee schedule database contains the percentage (shown in decimal format) for the intraoperative portion of the global package that shows 0.69 which means 69 % of allowed amount would be reimbursed for the physician who performs only the Surgical care.

For submitting claims to commercial insurances both physicians need to determine what percentage of the overall fee each bills for the individual services (for example, 70 percent for the surgery and 30 percent for the postoperative care). Do not bill more than 100 percent for the services provided. The sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services.

The reimbursement from the commercial insurances differs and depends upon their Split Surgical Package. For example BCBS of Florida would reimburse 70% for the procedure codes submitted with Modifier 54. UHC reimbursement for the procedure codes with Modifier 54 is 80 % in Maryland whereas only 50 % in the state of Florida.

Related Links:

Modifier -55 Postoperative Management Only - Usage and Reimbursement

Modifier -56 Preoperative Management Only - Usage and Reimbursement

References:

BCBSF reimbursement for claims submitted with Modifiers 54, 55 and 56 (Global Surgical Split Billing).

UHC reimbursement for claims submitted with Modifiers 54, 55 and 56 (Global Surgical Split Billing).

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