CurrentBlue Cross Blue Shield - WisconsinPolicy C-23004

Split-Care Surgical Modifiers - Professional

Policy governing reimbursement for surgical procedures billed with split-care modifiers (Modifiers 54, 55, 56) for professional providers under Blue Cross Blue Shield - Wisconsin.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicySplit-Care Surgical Modifiers - Professional

Policy CodePolicy C-23004

Change TypeMinor / no material changes

Effective DateJun 14, 2023

Next Review DateN/A

Key ActionEnsure proper billing and submission; claims with split-care modifiers submitted after a paid global surgical claim 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

CapGlobal package cap

Split-care modifier coverage criteria

Conditions and payment rules when split-care modifiers are appended to surgical procedure codes:

Use the same surgical procedure code (with the appropriate split-care modifier) by each physician performing components of the global package.

Reimbursement is determined by modifier: Modifier 54 (surgical care only) reimbursed at 70%; Modifier 55 (post-operative care only) reimbursed at 20%; Modifier 56 (pre-operative care only) reimbursed at 10%.

Special rules for Modifier 55: when postoperative management is for a time frame less than the published postoperative global period, report modifier 52 (reduced services) in addition to modifier 55 to reduce the calculated reimbursement for modifier 55 by 50%; services with modifier 55 appended to procedures that have zero postoperative days are not eligible for reimbursement.

Total reimbursement to all physicians for a global surgical package may not exceed the amount that would have been paid if a single physician provided all services (global package cap).

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

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

The health plan follows the standard definitions in the Related Coding section for Modifiers 54, 55, and 56.

Split-care modifiers and coding/reimbursement

Split-care modifiers and reimbursement ratesModifierCovered

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

Reimbursement rules

Reimbursement basisReimbursement 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.

Modifier-specific percentagesModifier 54 reimbursed at 70%; Modifier 55 reimbursed at 20%; Modifier 56 reimbursed at 10%.

Fee schedule capTotal amount reimbursed to all physicians for a global surgical package may not exceed the amount that would be paid if a single physician provided all services.

Uniform coding requirementEach physician must use the same surgical procedure code with the appropriate split-care modifier to identify services when components of the global package are performed by different physicians.

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

Billing, authorization, and submission requirements

Denial Risk

Billing, authorization and denial risk for late split-care claims

Ensure claims are billed with industry-standard, compliant CPT/HCPCS/revenue codes that are fully supported in the medical record; services must meet authorization and medical necessity requirements. Claims with split-care modifiers submitted after a global surgical claim has been paid will be denied.

Use proper billing and submission guidelines and compliant procedure codes on all claim submissions; documentation must support billed services.
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.
Claims with split-care modifiers received after a global surgical claim has been paid will be denied.

Definitions and package overview

Split-care surgical modifiers

Modifier 54Surgical care only — when one clinician performs the surgical procedure and another provides preoperative and/or postoperative management; reimbursed at 70%.

Modifier 55Post-operative care only — identifies the postoperative component when another performed the surgical procedure; reimbursed at 20%. When postoperative care is for less than the published postoperative global period, report modifier 52 in addition to modifier 55 to reduce reimbursement for modifier 55 by 50%. Procedures with zero postoperative days are not eligible for reimbursement with modifier 55.

Modifier 56Pre-operative care only — identifies the preoperative component when another performed the surgical procedure; reimbursed at 10%.

Global surgical package

Global package componentsIncludes preoperative services, the surgical procedure, and postoperative services.

Payment equivalenceTotal reimbursement for a global surgical package is the same regardless of how billing is split between different physicians involved in the member's care.

Aggregate payment capWhen more than one physician performs services included in the global package, the total amount reimbursed for all physicians may not exceed what would have been paid if a single physician provided all services.

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

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicySplit-Care Surgical Modifiers - Professional

Policy CodePolicy C-23004

Change TypeMinor / no material changes

Effective DateJun 14, 2023

Next Review DateN/A

Key ActionEnsure proper billing and submission; claims with split-care modifiers submitted after a paid 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.

Split-care modifier coverage criteria

Conditions and payment rules when split-care modifiers are appended to surgical procedure codes:

Use the same surgical procedure code (with the appropriate split-care modifier) by each physician performing components of the global package.

Total reimbursement to all physicians for a global surgical package may not exceed the amount that would have been paid if a single physician provided all services (global package cap).

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

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

The health plan follows the standard definitions in the Related Coding section for Modifiers 54, 55, and 56.

Split-care modifiers and coding/reimbursement

Split-care modifiers and reimbursement ratesModifierCovered

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

Reimbursement rules

Modifier-specific percentagesModifier 54 reimbursed at 70%; Modifier 55 reimbursed at 20%; Modifier 56 reimbursed at 10%.

Fee schedule capTotal amount reimbursed to all physicians for a global surgical package may not exceed the amount that would be paid if a single physician provided all services.

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

Billing, authorization, and submission requirements

Denial Risk

Billing, authorization and denial risk for late split-care claims

Use proper billing and submission guidelines and compliant procedure codes on all claim submissions; documentation must support billed services.
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.
Claims with split-care modifiers received after a global surgical claim has been paid will be denied.

Definitions and package overview

Split-care surgical modifiers

Modifier 54Surgical care only — when one clinician performs the surgical procedure and another provides preoperative and/or postoperative management; reimbursed at 70%.

Modifier 56Pre-operative care only — identifies the preoperative component when another performed the surgical procedure; reimbursed at 10%.

Global surgical package

Global package componentsIncludes preoperative services, the surgical procedure, and postoperative services.

Payment equivalenceTotal reimbursement for a global surgical package is the same regardless of how billing is split between different physicians involved in the member's care.

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

OpenPayer

Split-Care Surgical Modifiers - Professional

Split-care modifier coverage criteria

Split-care modifiers and coding/reimbursement

Billing, authorization, and submission requirements

Definitions and package overview

Don't let policy changes catch you off guard

Don't let policy changes catch you off guard

OpenPayer

Split-Care Surgical Modifiers - Professional

Split-care modifier coverage criteria

Split-care modifiers and coding/reimbursement

Billing, authorization, and submission requirements

Definitions and package overview