Understanding Modifier 55 in Medical Billing

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Introduction

This article guides using Modifier 55 for split billing in surgical scenarios, as outlined by the Centers for Medicare & Medicaid Services (CMS) and other major payers. 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 by 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.’

When Split Billing Applies

Modifier 55 comes into play when different physicians share responsibility for a global surgical package. This typically occurs when:

One physician performs the surgery and another handles postoperative care. This might happen due to patient travel distance, specialized expertise, or other valid reasons.
Physicians from different groups practice collaborate. In such cases, clear agreements on service division and documentation are essential.

Key Points for Modifier 55

When a patient travels far for surgery or requires specialized postoperative care unavailable at the surgeon’s location, care might be transferred to another physician after the surgery. In such cases, both physicians agree on the transfer and document it. If a surgeon performs the surgery but another physician with different expertise manages the postoperative period, Modifier 55 is appropriate.

Identify Postoperative Services: Modifier 55 is appended to the relevant surgical procedure code to indicate the physician managing postoperative care after another provider performed the surgery.
Clear Documentation: Both involved physicians must maintain written transfer agreements outlining the care division, the start and end dates of each responsibility, and communication protocols.
Billing Rules:
- Date of Service: Use the surgery date for both claims.
- Distinguish Services: Differentiate surgical care (Modifier 54) and postoperative care (Modifier 55) on separate claims with the same procedure code.
- Receiving Physician Billing: The physician assumes postoperative care bills only after their first service to the patient.

Key Guidelines

Both the surgeon’s bill (surgical care only) and the other physician’s bill (postoperative care only) use the same date of service and surgical procedure code.
Modifier 55 is appended to the physician’s bill for postoperative care.
The sum of payments to both physicians cannot exceed the global surgical package amount, except in specific situations outlined by payers.
Both physicians must maintain copies of the written transfer agreement in the patient’s medical record.
The receiving physician must provide at least one service before billing for any part of the postoperative care.

Invalid Modifier Combinations

Modifier 55 is not valid for:

Assistant surgeon services
Facility fees of Ambulatory Surgery Centers (ASCs)
Obstetric care (specific codes exist for shared care)
Procedures with a 0-day postoperative period
E/M, anesthesia, radiology, lab, medicine, ambulance, or non-surgical HCPCS codes
Provider types not subject to the global surgery concept (assistant surgeons, ASCs, outpatient/inpatient hospitals)

To conclude,

Modifier 55 plays a vital role in accurate billing for split surgical care. By understanding its proper application and adhering to the guidelines, healthcare providers can ensure appropriate reimbursement and avoid potential claim denials. Remember to stay updated on any payer-specific requirements and consult the latest coding resources for the most accurate information.

We hope this article has given you all the necessary information required to use modifier 55 appropriately. If you are still not sure and need help with medical billing for your practice, you can always contact us. PrimeCare has an experienced billing and coding team that uses exact modifiers to bring accurate insurance reimbursement. Contact us today to learn more about our billing and coding services.

References:

The American Medical Association (AMA) owns the copyright for the Current Procedural Terminology (CPT) coding system. The AMA developed and maintains the CPT code set, regularly updating it to reflect changes in medical practices, technology, and healthcare regulations.

Understanding Modifier 55 in Medical Billing