CurrentBlue Cross Blue Shield - MainePolicy N/A

Split-Care Surgical Modifiers Reimbursement

Governs reimbursement rules for surgical procedure codes when surgical care is split among multiple providers and specifies how split-care modifiers affect payment for members covered by AMH Health / Blue Cross Blue Shield - Maine.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicySplit-Care Surgical Modifiers Reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionUse the same surgical procedure code with the appropriate split-care modifier for each physician; claims with split-care modifiers submitted after a global surgical claim will be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

80%Modifier 54 reimbursement

20%Modifier 55 reimbursement

Not PayableModifier 56 reimbursement

01/01/2020Effective

01/30/2023Last review

Split-care Reimbursement Criteria

Split-care reimbursement criteria

AMH Health allows reimbursement of surgical codes appended with split-care modifiers when specific billing and payment rules are met:

ALL of the following

The same surgical procedure code with the appropriate split-care modifier must be used by each physician performing components of the global surgical package.
Reimbursement is based on a percentage of the fee schedule or contracted/negotiated rate for the surgical procedure; the percentage is determined by the modifier appended to the procedure code.
Total reimbursement for all physicians may not exceed the amount that would have been paid if a single physician provided all services in the global surgical package.
Claims received with split-care modifiers submitted after a global surgical claim has been paid will be denied.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicySplit-Care Surgical Modifiers Reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionUse the same surgical procedure code with the appropriate split-care modifier for each physician; claims with split-care modifiers submitted after a global surgical claim will be denied.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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Billing Requirements and Denial Risks

Denial Risk

Timing and denial risk for split-care modifier claims

Claims submitted with split-care modifiers after a global surgical claim has been paid will be denied.

Billing Rule

Coding requirement for split-care billing

Use the same surgical procedure code with the appropriate split-care modifier for each physician who performs components of the global surgical package; reimbursement is apportioned based on the modifier appended to the procedure code.

Modifier 54 identifies surgical care only (reimbursed at 80%).
Modifier 55 identifies post‑operative care only (reimbursed at 20%).
Modifier 56 identifies pre‑operative care only (Not Payable).

Key Definitions

Global surgical package

DefinitionGlobal surgical package consists of preoperative services, surgical procedures, and postoperative services; total reimbursement is the same regardless of how billing is split between physicians.

Reimbursement ruleReimbursement is based on a percentage of the fee schedule or contracted/negotiated rate for the surgical procedure; the percentage is determined by the split-care modifier appended to the procedure code.

Aggregate payment limitThe total amount reimbursed for all physicians may not exceed the amount that would have been paid if a single physician provided all services.

Coding requirementThe same surgical procedure code with the appropriate modifier must be used by each physician performing components of the global surgical package.

Modifier 54 — Surgical care only

ModifierModifier 54 - Surgical care only.

DescriptionWhen one physician performs the surgical procedure and another provides preoperative and/or postoperative management; identify the surgical services by adding modifier 54 to the usual procedure number.

ReimbursementReimbursed at 80% of the fee schedule or contracted/negotiated rate.

Modifier 55 — Post-operative care only

ModifierModifier 55 - Post-operative care only.

DescriptionWhen one physician performed the postoperative management and another performed the surgical procedure; identify the postoperative component by adding modifier 55 to the usual procedure number.

ReimbursementReimbursed at 20% of the fee schedule or contracted/negotiated rate.

Modifier 56 — Pre-operative care only

ModifierModifier 56 - Pre-operative care only.

DescriptionWhen one physician performed the preoperative care and evaluation and another performed the surgical procedure; identify the preoperative component by adding modifier 56 to the usual procedure number.

Reimbursement statusNot payable.

OpenPayer

Split-Care Surgical Modifiers Reimbursement

Split-care Reimbursement Criteria

Split-care Surgical Modifiers and Codes

Billing Requirements and Denial Risks

Key Definitions

54	Modifier 54 - Surgical care only; Reimbursed at 80%.
55	Modifier 55 - Post-operative care only; Reimbursed at 20%.
56	Modifier 56 - Pre-operative care only; Not Payable.