The description of modifier 55, the coding guidelines, billing requirements and reimbursement can be found below.
55 Modifier Description
The CPT Manual describes modifier 55 as: “When one physician performed the postoperative management only modifier and another physician performed the surgical procedure, the postoperative component may be identified by adding modifier 55 definition to the usual procedure number.”
Coding Guidelines For Modifier 55
- Use with surgical codes only to indicate that only the postoperative care was performed.
- Do not submit modifier 55 on CPT codes that has 0 days Global period. For example CPT 45378 (Colonoscopy diagnostic)
- Do not submit modifier 55 on E & M services.
- Do not submit modifier 55 along with other Global Surgical split billing modifier 54 and modifier 56.
- Do not submit modifier 55 along with modifier 80 (Assistant Surgeon), modifier 81 (Minimum Assistant Surgeon), modifier 82 (Assistant Surgeon when qualified resident surgeon not available) and modifier AS (Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant-at-surgery, non-team member).
- Do not report modifier 55 along with CPT 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure)
Billing Requirements For Modifier 55
Modifier 55 is used to identify postoperative, out of hospital medical care associated with a given surgical procedure. When billing for postoperative care only, report the original date of surgery as your date of service and the procedure code for the surgical procedure followed by the 55 modifier. In rare situations where the out of hospital postoperative care is split between physicians, each physician must also indicate the period of his/her responsibility for the patient’s postoperative care by reporting the appropriate range of dates. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service.
Physicians who share postoperative management must coordinate their billing. Physicians who share postoperative management with another physician must submit information on their claims showing when they assumed or relinquished responsibility for the postoperative care. In item 19 of the Form CMS-1500 or the electronic equivalent enter “Assumed Post-op Date=MM/DD/CCYY” or “Relinquished Post-op Date = MM/DD/CCYY.”
If more than one physician bills for the postoperative care, apportion the postoperative percentage according to the number of days each physician was responsible for the patient’s care.
Modifier 55 Reimbursement
Payment is limited to the allotted amount of postoperative 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 post-operative portion of the global package that shows 0.21 which means 21 % of allowed amount for CPT 27447 would be reimbursed for the physician who performs only the post-operative care.
The reimbursement from the commercial insurances differs and depends upon its Split Surgical Package. For example BCBS of Florida would reimburse 30% for the procedure codes submitted with Modifier 55. UHC reimbursement for the procedure codes with Modifier 55 is 20 % in Maryland whereas 30 % in the state of Florida.