Modifier 54: Appropriate Use
Split Surgical Care
There are occasions when more than one physician may furnish aspects of the services included in the global surgical package. When different physicians of a group practice participate in the care of the surgical patient, the group practice bills for the entire global surgical package. The physician who performs the surgery is reported as the performing physician. The other surgeons from the group are compensated for their participation in accordance with the group practice’s internal procedures and agreements.
However, it may be the case that one physician performs the surgical procedure and another physician from a different group practice furnishes the postoperative follow-up care. This may occur due to the distance from home a patient traveled for the surgical procedure, the type of procedure or practice, or for other reasons. In these cases, the physicians involved agree on the transfer of care and must keep documentation of the agreement, and the date the transfer of care occurred.
When the global surgery care is transferred from one physician to another in this manner, modifiers 54 and 55 are designated for use to identify which physician performed the components of the global surgical package. Collectively, modifiers 54 and 55 may be referred to as ‘split care modifiers.’
Modifier 54: Surgical Care Only
When one physician or other qualified heath care professional performs a surgical procedure and another provider preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
When components of a global surgical procedure are furnished by different providers each provider is expected to report only the service they performed and identify that service with the appropriate modifier and with the surgery date listed as the date of service, in accordance with correct coding guidelines. Indicate elsewhere on the claim the date care was relinquished or assumed. Where a transfer of postoperative care occurs, the receiving physician providing the postoperative follow-up care may not bill for any part of the global services until after he/she has seen the patient for the first postoperative visit/service.
Exception: Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of office visit code. The physician who performs the emergency room service bills for the surgical procedure without a modifier.
Modifier 54 Guidelines
- When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services, except where stated policies allow for a higher payment. For instance, when the surgeon furnishes only the surgery and a physician other than the surgeon furnishes pre-operative and post-operative inpatient care, the resulting combined payment may not exceed the global allowed amount.
- Both the bill for the surgical care only and the bill for the postoperative care only will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.
- Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. 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.
- Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.
- Where physicians agree on the transfer of care during the global period, the following modifiers are used:
- Modifier 54: for surgical care only; or
- Modifier 55: for postoperative management only
- Both the bill for the surgical care only and the bill for the postoperative care only will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.
Invalid Split Care Modifier Combinations
- Modifiers 54, 55, and 56 are not considered valid for obstetric care procedure codes, as specific codes already exist to identify when more than one provider provides antepartum, delivery, and postpartum care.
- Modifiers 54, 55, and 56 do not apply to procedure codes with a 0-day postoperative period.
- Modifiers 54, 55, and 56 are not considered valid for E/M, anesthesia, radiology, laboratory, medicine, or ambulance procedure codes, or any non-surgical HCPCS code.
- Modifiers 54, 55, and 56 are not considered valid for provider types to which the global surgery concept and a postoperative care global period do not apply: Assistant surgeons; Ambulatory Surgery Centers; Outpatient Hospitals; and Inpatient Hospitals.
CPTs and Modifiers © Copyright 2021 American Medical Association
We hope this article would have given you all the necessary information required to use modifier 54 appropriately. If you are still not sure and need help in medical billing for your practice, you can always contact us. E2E Medical Billing Services has an experienced billing and coding team that uses exact modifiers to bring accurate insurance reimbursement. To know more about our medical billing services call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com