Understanding Modifier 56 in Medical Billing
Introduction
In many surgical cases, multiple healthcare providers contribute to the patient’s care. Modifier 56 plays a crucial role in accurate billing when one physician performs preoperative care and evaluation, while another individual performs the actual surgery.
What is Split Surgical Care?
Sometimes, more than one physician might contribute to the services included in a global surgical package. This is known as “split surgical care.” When different physicians within a group practice participate, the group generally bills for the entire package under the performing surgeon’s name. However, individual compensation within the group is determined by their internal agreements.
When to Use Modifier 56
Modifier 56 (“Preoperative Management Only”) is used when one physician (or other qualified healthcare professional) performs the preoperative care and evaluation, while another performs the surgery itself. This might occur when:
- The patient has a pre-existing condition: If the patient has a condition like heart disease that could impact surgery, the surgeon might consult a specialist for pre-operative clearance. In this case, the specialist bills for their consultation using the appropriate code, but not the surgical code with Modifier -56.
- Complex surgery requiring specialized pre-op assessment: Some complex surgeries might necessitate specific pre-operative assessments by another physician with relevant expertise. Modifier -56 is appropriate here if they don’t participate in the surgery.
When Modifier -56 applies, please attach it to the usual procedure code billed by the surgical provider. Remember, the sum of payments for all involved physicians cannot exceed the global surgical package allowance unless specific policies permit higher payments.
Invalid Modifier 56 Combinations
- Global payment limits: The total amount paid to all involved physicians cannot exceed what would be paid if a single physician provided everything, except in specific cases with higher allowed payments.
- Invalid Modifier combinations: Modifier -56 is not valid for:
- 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 exempt from the global surgery concept (e.g., assistant surgeons, ASCs, OPDs, IHs)
- Inaccurate use example: A patient with heart disease requires abdominal surgery. The surgeon performs routine preoperative care, while the cardiologist provides clearance through an office visit billed with an appropriate consultation code. The cardiologist does not bill the surgical code with Modifier -56.
- Medicare disclaimer: While generally applicable, Modifier 56 might not be recognized by Medicare. Consult official guidelines or seek professional advice for Medicare-specific billing practices.
Important Coding Considerations
- Group practices and internal agreements: While group practices generally bill for the entire global surgical package, it’s essential to understand how internal agreements affect Modifier -56 usage. Ensure that compensation for participating physicians aligns with internal policies and adheres to Modifier 56 guidelines.
- Routine preoperative care and modifier 56: The surgeon typically handles routine preoperative tasks like discussing the surgery, assessing patient suitability, preparing documents, and obtaining consent. Modifier 56 is not applicable in these scenarios.
- Consultations for specific conditions: If a patient has a pre-existing condition posing additional surgical risk, the surgeon may refer them to a specialist or internist for clearance. This specialist bills for their services using an appropriate consultation code and diagnosis, not the surgical code with Modifier 56.
PrimeCare is a leading medical billing company. This article has been shared to educate healthcare providers. You are requested to consult with a qualified healthcare professional or billing expert for specific guidance on using Modifier 56 and navigating relevant regulations.
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.
