CurrentBlue Cross Blue Shield - NevadaPolicy C-23004

Split-Care Surgical Modifiers - Professional

Defines reimbursement treatment when components of a global surgical package are split among multiple physicians and describes modifier-specific payment percentages for professional claims.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicySplit-Care Surgical Modifiers - Professional

Policy CodePolicy C-23004

Change TypeNo material change

Effective DateJun 14, 2023

Next Review Date

Key ActionBill the same surgical procedure code with the appropriate split-care modifier and provide documentation to support the claim; claims with split-care modifiers submitted after a global surgical claim has been paid will be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

70%Modifier 54

20%Modifier 55

10%Modifier 56

nonepolicy exemptions

split from C-08007origin

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.

Split-care reimbursement criteria

Covered when ALL of the following conditions are met:

Provider must bill the same surgical procedure code with the appropriate split-care modifier to identify the component performed when components of the global surgical package are split among different physicians.

Reimbursement is 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.

Total combined payments to multiple physicians may not exceed the payment that would have been made if a single physician performed 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.

Assistant surgeon and multiple procedure rules and fee reductions apply when an assistant surgeon is used and/or multiple procedures are performed.

ALL of the following

Modifier 54 (surgical care only) — reimbursed at 70%.
Modifier 55 (postoperative care only) — reimbursed at 20%. If postoperative management is for less than the published postoperative global period, report modifier 52 in addition to modifier 55 to reduce the calculated reimbursement for modifier 55 by 50%. Procedures with zero postoperative days are not eligible for reimbursement with modifier 55.
Modifier 56 (preoperative care only) — reimbursed at 10%.

The health plan will use the standard definitions in the Related Coding section to determine modifier application and payment calculations.

Split-care Modifiers and Reimbursement

Split-care modifiersModifierCovered

54	Surgical care only
55	Post-operative care only
56	Pre-operative care only

Modifier reimbursement notesmixed

54	Reimbursed at 70%
55	Reimbursed at 20%; when combined with modifier 52 for reduced postoperative timeframe, reimbursement for modifier 55 is reduced by 50%; procedures with zero postoperative days are not eligible for reimbursement with modifier 55
56	Reimbursed at 10%

Reimbursement percentages by modifier

Modifier 54Reimbursed at 70% of the fee schedule or contracted rate when billed for surgical care only.

Modifier 55Reimbursed at 20% of the fee schedule or contracted rate for postoperative care only; if reported with modifier 52 for a reduced postoperative timeframe, reimbursement for modifier 55 is reduced by 50%; procedures with zero postoperative days are not eligible for reimbursement with modifier 55.

Modifier 56Reimbursed at 10% of the fee schedule or contracted rate for preoperative care only.

Authorization and Claims Submission Rules

Documentation Required

Authorization, coding, and timely claims submission requirements

Ensure services meet authorization and medical necessity guidelines and use proper CPT/HCPCS coding and documentation to support claims; bill the same surgical procedure code with the appropriate split‑care modifier when components of a global surgical package are performed by different physicians. Claims with split‑care modifiers submitted after a global surgical claim has been paid will be denied.

Use industry‑standard CPT, HCPCS, and/or revenue codes and ensure codes are fully supported in the medical record or office notes.
Bill the identical surgical procedure code with the appropriate split‑care modifier (54, 55, or 56) to identify the component performed.
Confirm services meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member’s state of residence.
Do not submit split‑care modifier claims after a global surgical claim has been paid — such claims will be denied.

Key Definitions

Global surgical package

ComponentsIncludes preoperative services, the surgical procedure, and postoperative services.

Reimbursement basisTotal reimbursement for the global surgical package is based on the global package and is the same regardless of how billing is split among physicians.

Combined payment limitWhen multiple physicians perform components, the total reimbursed to all physicians may not exceed what would have been paid if one physician provided all services.

Modifier 54 — Surgical care only

DefinitionSurgical care only — used when one practitioner performs the surgical procedure and another provides preoperative and/or postoperative management.

ReimbursementReimbursed at 70% of the fee schedule or contracted/negotiated rate.

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

Modifier 55 — Postoperative care only

DefinitionPostoperative care only — used when one practitioner performed postoperative management and another performed the surgical procedure.

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

Reduced postoperative timeframe ruleIf postoperative management is for less than the published postoperative global period, report modifier 52 in addition to 55 to reduce the calculated reimbursement for modifier 55 by 50%.

Zero-day exclusionProcedures with zero postoperative days are not eligible for reimbursement with modifier 55.

Modifier 56 — Preoperative care only

DefinitionPreoperative care only — used when one practitioner performed preoperative care and evaluation and another performed the surgical procedure.

ReimbursementReimbursed at 10% of the fee schedule or contracted/negotiated rate.

Coding noteIdentify the preoperative component by appending modifier 56 to the usual procedure number when splitting care.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicySplit-Care Surgical Modifiers - Professional

Policy CodePolicy C-23004

Change TypeNo material change

Effective DateJun 14, 2023

Next Review Date

SourceLink

On This Page

OpenPayer

Split-Care Surgical Modifiers - Professional

Split-care Reimbursement Criteria

Split-care Modifiers and Reimbursement

Authorization and Claims Submission Rules

Key Definitions

Split-Care Surgical Modifiers - Professional

Split-care Reimbursement Criteria

Split-care Modifiers and Reimbursement

Authorization and Claims Submission Rules

Key Definitions

Related Policies and Policy History