Modifier 54, 54 modifier

54 Modifier – Description, Billing Guidelines & Reimbursement

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

Description

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.

Billing Guidelines

  • Submit the 54 modifier 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 the 54 modifier on E & M services.
  • Do not submit the 54 modifier modifier 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 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 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.

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.

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.

Related Links

Modifier 55 Postoperative Management Only – Usage and Reimbursement

Modifier 56 Preoperative Management Only – Usage and Reimbursement

Similar Posts

Leave a Reply

Your email address will not be published.