Modifier -56 Preoperative Management Only - Usage and Reimbursement

Preoperative Management Only: When one physician performed the preoperative care and evaluation and another physician performed the surgical procedure, the preoperative component may be identified by adding the modifier -56 to the usual procedure number.

Use with surgical codes only to indicate that only the pre-operative care was performed.

Do not submit modifier 56 on CPT codes that has 0 days Global period. For example CPT 45378 (Colonoscopy diagnostic)

Do not submit modifier 56 on E & M services.

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

Do not submit modifier 56 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:

Medicare does not recognize the use of Modifier -56 though Medicare physician Fee schedule database contains a field that shows a percentage of 10 % of the actual allowed amount if a physician performed only the Pre-operative portion of a surgery.

All major commercial insurances will follow these CMS designations and the reimbursement will be 10 % for the Pre-operative portion of the surgery that has a Global Days field equal to 010 or 090 on the Medicare Physician Fee Schedule Relative Value file.

Related links:

Modifier -54 Surgical Care Only - Usage and Reimbursement

Modifier -55 Postoperative Management Only - Usage and Reimbursement