Modifier 56: 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.
During the preoperative visit, the surgeon discusses the surgery to be performed, evaluates the patient’s condition and ability to tolerate the planned surgery, prepares the admission documents, and has the patient sign the appropriate consent forms. These services are not customarily delegated to another physician.
In some instances, the patient may have an ongoing physical problem that could pose an additional risk during surgery. In such a case, the surgeon may send the patient to a specialist or their internist for surgical clearance. When this occurs, the specialist or internist will bill for the appropriate consultation or office visit and use the patient’s condition as the primary diagnosis.
Modifier 56: Preoperative Management Only
When one physician or other qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number.
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 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.
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.
Example of Modifier 56
If abdominal surgery is planned for a patient with underlying heart disease, the surgeon may wish to have the patient’s cardiologist examine the patient and give the patient a preoperative clearance. In this instance, the surgeon will still do the routine preoperative care and the cardiologist will bill for an established patient office visit. Note that the cardiologist would not bill the surgical code with modifier 56.
We hope this article would have given you all the necessary information required to use modifier 56 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
Modifiers and their descriptions discussed in this article do not reflect or guarantee coverage or payment. Just because a CPT code/ modifier exists, payment for the service it describes is not guaranteed. Coverage and payment policies of governmental and private payers vary from time to time and for different areas of the country.