Modifier 54 | Surgical Care Only Explained

Modifier 54 describes surgical care only, which is one of the three components of a surgical package.

1. What is modifier 54?

Modifier 54 represents intraoperative services, which is the actual surgical procedure performed by the provider. It is used when the provider performs the procedure but does not provide preoperative or postoperative management.

2. When to use modifier 54?

Modifier 54 is appropriate when different providers render different components of care or when a provider transfers the patient’s care to another provider. Providers transfer care for various reasons, including the patient relocating to another geographic area or complications requiring another provider to monitor his care.

3. Description

The official description of modifier 54 is surgical care only, which represents the actual procedure performed by the provider.

4. Examples

Examples of procedures that require modifier 54 include surgeries where the surgeon performs the procedure. Still, the patient is transferred to another provider for postoperative care or when the surgeon performs the procedure, but another provider provides preoperative care.

5. Documentation

To use modifier 54, the provider needs to document the reason for providing shared care in the medical record before the surgery and the patient’s understanding and agreement to the care plan.

6. Billing

When billing with modifier 54, list the provider who rendered the intraoperative services in block 31 of the CMS 1500 claim form. The insurance will send one payment to the provider who rendered the intraoperative services and a separate payment to the provider who rendered the preoperative or postoperative services.

7. Common mistakes

Medical coders make common mistakes when using modifier 54, including appending the modifier when different providers working for the same group practice render different components of the surgery or when two providers do not share the patient’s care. To avoid these mistakes, ensure that the providers perform the comanagement service for the patient’s benefit, not the practice’s financial benefit.

8. Other modifiers related to modifier 54

Other modifiers related to modifier 54 include modifier 55, which represents postoperative management only, and modifier 56, which represents preoperative management only.

9. Tips

When using modifier 54, ensure that the provider performs the surgical procedure, not the preoperative or postoperative services. Also, append a comanagement modifier only when two providers share the patient’s care. Ensure that the providers perform the comanagement service for the patient’s benefit, not the practice’s financial benefit.