How will you bill a claim when a surgeon performs a procedure but hands over follow-up care to another physician? How will you split the payment received as a global surgical package between surgery and postoperative care? The answer is modifier 55.
Our billing experts at MediBillMD have created this detailed guide to help you understand what this modifier is and how you can use it in your billing the right way. So, let’s start.
Modifier 55 – Description
Modifier 55 is defined as:
“Postoperative Management Only.”
Let’s break this down in more detail. Modifier 55 is appended to a surgical procedure code when one physician performs the surgery, and a different physician or other qualified healthcare professional takes over all or part of the postoperative care.
You are essentially telling the payer that “I didn’t perform the surgery, but I managed this patient’s recovery”. Actually, this modifier is part of a trio, known as “split care modifiers,” that is used to divide the global surgical package between providers. Here is a brief description of all three:
- Modifier 54: Intraoperative or surgical care only. It is used by the physician who performed the surgery.
- Modifier 55: Postoperative management only. As we discussed, it is used by the provider who renders postoperative care.
- Modifier 56: Preoperative management only. Used by a provider to bill for the preoperative care.
Each modifier is applied to the same surgical CPT code. The reimbursement of surgical codes is not as simple as service codes. Payment for surgeries is divided into three parts: the surgery itself, pre- and post-surgical care. When you append the 55 modifier to a code, Medicare will only pay the postoperative care amount, which is typically 15% to 20% of the allowed surgical package.
However, an important thing to note here is that this modifier is valid only for procedures with a 10-day or 90-day global period.
Scenarios Where Modifier 55 is Applicable
To help you understand how the 55 modifier works practically in real scenarios, let’s look at a couple of examples:
The Surgeon is Unavailable After Surgery
Suppose a 70-year-old patient underwent cataract surgery (CPT 66984) on their right eye by Surgeon A. This procedure carries a 90-day global period. Immediately after the procedure, Surgeon A left the practice indefinitely, and Physician B from the same clinic agreed to take over all subsequent routine postoperative care and follow-up visits for the remaining 89 days of the global period.
In this case, the billing department would bill surgical CPT code 66984 with modifier 54 to account for the surgical portion performed by Surgeon A. Physician B’s office would use the same CPT code 66984 with modifier 55 to bill for the 89 days of postoperative care management they provided.
Fracture Care Transferred from the ED
Assume a patient is brought to the emergency department (ED). He was in a car accident and fractured his leg. The surgeon in the ED aligns the bones and holds them in place with metal plates (CPT code 27758). This procedure has a 90-day global period.
However, the hospital where the emergency service was performed is too far from the patient’s home. Hence, the patient follows up with another orthopedic consultant in a nearby hospital for ongoing postoperative management.
The first hospital’s billing department will bill CPT code 27758 with modifier 54 for the ED surgeon, and the second hospital will bill the same code with modifier 55 for postoperative care.
Modifier 55 – Billing Guidelines
Here are some additional guidelines that are essential to note:
- Even though the postoperative provider begins seeing the patient after the surgery, the date of service on the claim must reflect the date of the surgery, not the date of the first follow-up visit.
- On the CMS-1500 claim form, the provider should document the date span of assumed postoperative care in Item 19 (or the electronic equivalent).
- A formal or informal transfer of care must take place before billing with modifier 55.
- Modifier 55 should not be appended to ambulatory surgical center (ASC) claims or assistant surgeon claims.
- Submit the claim with the number of units as 1.
Final Word
Let’s summarize everything we have discussed so far.
- Modifier 55 is used to inform payers that the physician is only billing for postoperative care.
- It is only appended to surgical CPT codes with 10- or 90-day global periods.
- On the insurance claim, the date of surgery should be mentioned, and not the date of the first follow-up visit.
- Document a formal transfer of care and submit the letter with the claim form to support the use of this modifier.
Medical billing and coding are complex and frustrating. Even with all the guidelines, denials are likely to occur. That’s why it is better to outsource medical billing services and other RCM operations to specialized companies like MediBillMD.
