Coding Tip – Surgical Package Modifiers

This article written by MedSafe Billing and Coding Specialist, Mike Enos.

In this coding tip, we will review a few modifiers that specify which portion of the surgical package the provider is billing for.  The global surgical package includes payment for services that are a necessary part of a procedure.  For example, the global package includes not just payment for the surgical procedure itself, but also preoperative visits after the decision is made to operate, postoperative visits related to recovery, postsurgical pain management, supplies, and other miscellaneous services such as dressing changes, removal of sutures or casts, etc.

There are many occasions when more than one physician provides services that are included in the global surgical package.  For example, sometimes the physician who performs the surgical procedure does not furnish the follow-up care.  Let’s say a child from Florida is vacationing in Massachusetts and fractures their leg while sledding.  Payment for the postoperative care is split between two or more physicians of different groups, since there is a transfer of care when they return home.  When that happens, the following modifiers are used:

·         Modifier 54 – Surgical Care Only.  This modifier is used when the provider only performed the surgical procedure, but none of the preoperative or postoperative work associated with it.

·         Modifier 55 – Postoperative Management Only.  Use this modifier when the provider furnished postoperative services, but another provider performed the surgical procedure.

Both providers would bill the CPT code associated with the surgical procedure, and both would bill for the date of service of the procedure – the difference would be the use of the modifiers above to indicate which portion of the surgical package they furnished.  Be sure to also document the date of the transfer of care- that should be transmitted on the claim as well.

One exception to this would be for physicians who provide follow-up services for minor procedures performed in emergency department – they would actually bill an Evaluation and Management service (for example a 99203 new patient office visit.)  In that case, the physician who performs the emergency room service would bill for the surgical procedure without a modifier.

For more information about the global surgical package and use of modifiers 54 and 55, check out the Medicare Claims Processing Manual Chapter 12 Section 40.2.A.3 or this Modifier 54 Fact Sheet.