CurrentColorado Rocky Mountain Health PlansPolicy 2026R9035A

Split Surgical Package / Global Surgical Package modifiers 54 and 55 reimbursement

Defines UnitedHealthcare Medicare Advantage reimbursement rules for global surgical packages and split/shared situations for services billed on CMS 1500 (professional) claims, including use of modifiers -54 and -55 and payment split when different physicians provide portions of the global package. Applies to network physicians and other qualified health care professionals billing Medicare Advantage products.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySplit Surgical Package / Global Surgical Package modifiers 54 and 55 reimbursement

Policy CodePolicy 2026R9035A

Change TypeAnniversary review

Effective Date

Next Review DateJun 1, 2026

Key ActionWhen care is transferred during the global period, maintain a written transfer agreement in the beneficiary's medical record and bill using the same CPT code and surgery date with the appropriate modifier (-54 or -55).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

80%typical payment portion for modifier 54 (surgery)

20%typical payment portion for modifier 55 (postoperative care)

0%typical payment portion for modifier 56

100%maximum combined payment for split surgical package

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When Separate Reimbursement Applies

When postoperative care may be billed separately

Covered when ALL of the following are met:

ALL of the following

Postoperative care is furnished by a physician or other qualified health care professional who is not within the Same Group Practice as the operating physician.
The surgical code is reported with modifier -55 by the physician providing postoperative management.
The date of surgery is reported as the date of service and the date care was assumed or relinquished is indicated.
The receiving physician provides at least one service before billing for any part of the postoperative care.
A written transfer agreement is kept in the beneficiary's medical record.
Modifier -55 is used with CPT codes that have a 10- or 90-day global period.
Apply only to CPT codes with 10- or 90-day postoperative global periods.

When preoperative care is not reimbursed separately

When the following ALL apply:

ALL of the following

When the operating physician bills with modifier -54, preoperative and surgical care portions are combined and preoperative care is not reimbursed separately.
Modifier -54 does not apply to assistant-at-surgery services.
Modifier -54 does not apply to ASC facility fees.

Payment limits for multiple physicians furnishing global package components

Limits and documentation requirements when more than one physician furnishes components of the global surgical package:

ALL of the following

The sum of amounts approved for all physicians may not exceed what would have been paid if a single physician provided all services, except where other policies allow higher payment.>= 100% of total global surgical allowable amount
Maximum combined payment capped at 100% of the total global surgical allowable amount.
If a surgeon performs only the surgery and another physician furnishes pre- and post-operative inpatient care, combined payment may be higher than the global allowed amount in some circumstances; a written transfer agreement must be kept.
Written transfer agreement must be kept in the beneficiary's medical record when care is transferred.
Where a transfer of care does not occur, services by another physician may be paid separately or denied for medical necessity depending on circumstances.

Modifiers and Billing Codes

Modifiers for split surgical packageModifierCovered

54	Surgical care only (surgeon relinquishing post-operative care)
55	Post-operative management only (physician assuming postoperative care)
56	Pre-operative management only (note: payment percentage listed as 0%)

What Providers Must Do

Documentation Required

Written transfer agreement required

When care is transferred between physicians during the global period, both the transferring and receiving physicians must keep a copy of the written transfer agreement in the beneficiary's medical record.

Billing Rule

Billing with appropriate modifiers and same CPT code

When using modifiers -54 or -55, report the same CPT code and the date of surgery on bills for surgical care only and post-operative care only; report the date of surgery as the date of service and indicate the date care was relinquished or assumed.

Report the identical CPT code on both the surgeon's (‑54) and the receiving physician's (‑55) claims.
Report the date of surgery as the date of service.

Scope and Resources

This policy defines UnitedHealthcare Medicare Advantage reimbursement rules for global surgical packages and split/shared situations for services billed on the CMS 1500 (professional) claim form. It applies to all network physicians and other qualified health care professionals billing Medicare Advantage products when submitting CMS 1500 claims, and addresses use of modifiers -54 (surgical care only) and -55 (post-operative care only), payment splits when different physicians provide portions of the global package, and documentation requirements when care is transferred.

Resources to support application of this policy include the CMS website, American Medical Association CPT publications, the Medicare Claims Processing Manual — Chapter 04 and Chapter 12, the Medicare Physician Fee Schedule (PFS) Relative Value Files, and the Medicare Learning Network (MLN) publication MM7872.

Payment Thresholds

Maximum combined payment100% of total global surgical allowable amount

Typical payment portion for modifier 54 (surgery)80%

Typical payment portion for modifier 55 (postoperative care)20%

Defined Terms

Definitions

Same Group Physician and/or Other Qualified Health Care ProfessionalAll physicians and/or other qualified health care professionals of the same group reporting the same Federal Tax Identification number.

Split Surgical PackageOccurs when a component of the surgical package (preoperative, surgical, postoperative) is rendered by a physician other than the physician performing the surgical service.

Surgical PackageIncludes preoperative visits (day before for major procedures, day of for others), services integral to the procedure, complications related to the procedure (not requiring additional OR trips), postoperative visits related to recovery, post-procedure pain management, supplies (except specified exclusions), and miscellaneous routine services such as dressing changes, suture removal, catheter insertion/removal and related routine care.

Policy Version History

2026-06-01Policy Version ChangeLatest

Anniversary review; history entries prior to 6/1/2024 were archived.

2025-06-01Policy Version Change

Policy version change; history entries prior to 6/1/2023 were archived.

2016-03-09New Policy

Policy established (new policy effective).