Did you know that in the United States, on average, 1.5 million patients are transferred between acute care hospitals annually? These transfers can be for several reasons. One of the most common reasons is to receive necessary treatments and services only available at other centers.
Have you ever encountered a ‘transfer of care’ case where the patient moves out after receiving preoperative care services, and another surgeon performs the procedure?
If yes, continue reading! The reason? We will discuss modifier 56 in detail. It is a two-digit code that can help you get reimbursement for the preoperative part of the surgery and prevent revenue leakage.
Modifier 56 – Description
Modifier 56 highlights to the payer that you were only responsible for the preoperative care management. Simply put, it makes it clear that you are not billing for intraoperative or postoperative services regarding the billed surgical procedure.
It is an essential modifier to split reimbursement between two healthcare providers. Besides, with this modifier, you receive 10% payment (typically) of the applicable fee schedule for a specific surgery.
Scenarios Where Modifier 56 is Applicable
Let’s review a few real-world clinical scenarios where this modifier applies:
Rural Transfer (Contract-Specific)
Imagine that a 32-year-old female patient who resides in a remote area underwent a complex neurosurgical procedure. However, prior to the procedure, which was performed by an out-of-network neurosurgeon, the primary care physician at her locality was responsible for the extensive preoperative medical optimization. It included managing brittle diabetes and hypertension, specifically for the stress of surgery. The primary care physician also coordinated clearance for surgery.
Soon after, the patient was flown to a reputable university hospital for surgery.
In this case, the primary care physician can append modifier 56 to the neurosurgery CPT code to bill for the preoperative care. Why? According to the physician-payer contract, the in-network primary care physician is allowed to submit a claim for preoperative services if the physicians performing the surgery are out-of-network providers.
Pulmonologist’s Pre-Op for Thoracic Surgery
For this scenario, assume that a 55-year-old male patient who is a chain smoker requires lung resection (CPT code 32480) as part of his cancer treatment. Before surgery, a pulmonologist conducts separate preoperative spirometry, bronchoscopy, and smoking cessation counseling as part of the global package. However, the thoracic surgeon is the one who will perform the lobectomy.
So in this case, the pulmonologist can append modifier 56 to CPT 32480 to bill for his preoperative services.
A Note of Caution: Please remember that modifier 56’s use is limited to rare cases. Most payers (including Medicare and commercial payers) do not recommend fragmented billing or splitting the global surgical package into preoperative, intraoperative, and postoperative care. This is because many of the preoperative services rendered by a separate physician are billed individually as either evaluation and management (E/M) services or pre-surgery exams. Healthcare providers prefer separate billing instead of taking a chunk from the global surgical package because it results in a higher reimbursement rate, rather than the typical 10% for preoperative care.
Modifier 56 – Billing Guidelines
The following are some essential billing guidelines to ensure the appropriate use of modifier 56:
When You Should Append Modifier 56
Discussed below is the key criterion for applying this modifier:
- There must be a formal transfer of care. That is, the medical records must prove that you performed preoperative management before the patient was transferred to a different physician for the intraoperative portion.
- It is applicable only to surgical codes.
When NOT to Use Modifier 56
Do not use it if any of the following is true:
- The same physician or a member of the same group practice also performs the surgery.
- You are billing for a standard office visit or evaluation and management (E/M) service code.
Documentation Requirements
Detailed and accurate documentation is a primary requirement to support the use of modifier 56 on the medical claim. Thus, ensure to include the following:
- A written note in the chart indicating that preoperative care was transferred to you, or that you are transferring the patient to another surgeon for the procedure.
- Mention the date the preoperative management was completed.
- Attach a comprehensive review of history and physical examination specifically tailored to the surgery.
Summary
Modifier 56 is an integral modifier that addresses special circumstances related to the ‘transfer of care’ and ensures that both healthcare providers are properly reimbursed.
However, keep in mind that it is only applicable to surgical procedures. If you try to split global package reimbursement for E/M visits, it can trigger audit risks and denials. So, be wary!
With that said, it is time to say adieu. Hopefully, this guide will help you ensure clean claim submissions. However, in case you struggle, feel free to outsource medical billing services to professionals, like MediBillMD.
