(2023) Modifier 54 | Surgical Care Only Explained

Are you looking for billing guidelines for the 54 modifier for surgical care only? Underneath the description, coding guidelines, and reimbursement for this modifier.

Description Of The 54 Modifier

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 the 54 modifier.

The official description of modifier 54 is: “Surgical Care Only.”

Billing Guidelines

• Submit the 54 modifier only with the surgical procedure code.
• Do not submit the 54 modifier along with other Global Surgical split billing modifier 55 and modifier 56.
• Do not submit modifier 54 on CPT codes that have a 0-day Global period.
• Do not submit the 54 modifier on E & M services.
• 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 only the amount allotted to the preoperative and intraoperative services for the 54 modifier.

Medicare has split global surgery package relative values into preoperative, intraoperative, and postoperative percentages.

For example: The CPT for Total Knee Arthroplasty 27447 has a Global period of 90 days, and a field in the 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 the allowed amount would be reimbursed for the physician who performs only the Surgical care.

The reimbursement from the commercial insurance 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 Florida.

For submitting claims to commercial insurance, both physicians need to determine what percentage of the overall fee each bill 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.

Go back to the list with all the CPT modifiers.