Friday, August 20, 2010

Surgical care Modifier - 54

Modifier 54 Fact Sheet

Definition:

• Modifier 54 indicates that the surgeon is billing the surgical care only.

Appropriate Usage:

• When all or part of the postoperative care is relinquished to a physician who is not a member of the same group
• Appended to the procedure code that describes the surgical procedure performed that has a 10 or 90-day postoperative period.

Inappropriate Usage:

• Appending modifier 54 to a surgical procedure without a global period or procedure other than 010 or 090 global days
• When the covering physician (i.e. locum tenens) belongs to the same group as the surgeon and the surgeon provided most of the postoperative care
• Appending to an E/M procedure code
• Appending to an assistant at surgery service

The Medicare Physicians Fee Schedule Database (MPFSDB) indicates the reimbursement percentages for each portion of the global period of major and minor surgical procedures.

Most major (90-day global period) surgeries reimburse 10% of the physician fee schedule amount for the pre-op, 70% for the intra-op and 20% for the post-op period.

Most minor (10-day global period) surgeries reimburse 10% of the physician fee schedule amount for the pre-op, 80% for the intra-op and 10% for the post-op period.

For example, Doctor A performs the pre-op visit and the major surgery; therefore, he receives 10% of the physician fee schedule amount for the pre-op period and 70% for the intra-op period when billing with modifier 54.Doctor B covers the patient for the entire post-op period; therefore, he
receives 20% of the physician fee schedule amount when billing with modifier 55.

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