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.

Using Modifiers “-54” and “-55” on Global Surgery period

Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier:

• Surgical care only (modifier “-54”)

• Post-operative management only (modifier “-55”)

The physician must use the same CPT code for global surgery services billed with modifiers “-54” or “-55.” The same date of service and surgical procedure code should be reported on the bill for the surgical care only and post-operative care only. The date of service is the date the surgical procedure was furnished.

Modifier “-54” indicates that the surgeon is relinquishing all or part of the post-operative care to a physician.

• Modifier “-54” does not apply to assistant-at-surgery services.
• Modifier “-54” does not apply to an Ambulatory Surgical Center (ASC’s) facility fees.

The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.”

• Use modifier “-55” with the CPT procedure code for global periods of 10- or 90-days.

• Report the date of surgery as the date of service and indicate the date that care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.

• The receiving physician must provide at least one service before billing for any part of the postoperative care.

• This modifier is not appropriate for assistant-at-surgery services or for ASC facility fees.


Exceptions to the Use of Modifiers “-54” and “-55”


Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate Evaluation and Management (E/M) code. No modifiers are necessary on the claim.

Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier.

If the services of a physician, other than the surgeon, are required during a post-operative period for an underlying condition or medical complication, the other physician reports the appropriate E/M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient,,



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