CurrentHighmark Blue Cross Blue Shield WnyPolicy G-11005

Reimbursement Policy Split Care Surgical Modifiers

Defines the health plan's reimbursement approach when components of a global surgical package are split between providers using split-care modifiers (Modifiers 54, 55, 56); applies to Highmark BCBS WNY reimbursements for the referenced member programs (EP noted) and to professional/surgical billing.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyReimbursement Policy Split Care Surgical Modifiers

Policy CodePolicy G-11005

Change TypeNo material changes

Effective DateAug 18, 2025

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and member's state of residence; follow proper billing/submission guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

70%Modifier 54 reimbursement

20%Modifier 55 reimbursement

10%Modifier 56 reimbursement

Global capGlobal cap

DeniedLate claims

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 Rules

Split-care reimbursement criteria

Reimbursement rules and percentages when components of the global surgical package are performed by different providers.

Use the same surgical procedure code with the appropriate split-care modifier for each physician who performs components of the global surgical package.

When more than one physician performs services that are included in the global surgical package, the total amount reimbursed for all physicians may not exceed the amount that would have been paid if a single physician provided all services.

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

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

Modifier 54: Surgical care only — When one clinician performs the surgical procedure and another provides preoperative and/or postoperative management; add modifier 54 to identify the surgical services.

Modifier 54 reimbursement: Reimbursement: 70% of the fee schedule or contracted/negotiated rate.

Modifier 55: Post-operative care only — When one clinician performed the postoperative management and another performed the surgical procedure; add modifier 55 to identify the postoperative component.

Modifier 55 reimbursement: Reimbursement: 20% of the fee schedule or contracted/negotiated rate.

Modifier 56: Pre-operative care only — When one clinician performed the preoperative care and evaluation and another performed the surgical procedure; add modifier 56 to identify the preoperative component.

Modifier 56 reimbursement: Reimbursement: 10% of the fee schedule or contracted/negotiated rate.

Assistant surgeon and multiple procedure rules and applicable fee reductions remain in effect when used.

Modifiers, Codes, and Billing Limits

Split-care surgical modifiersModifier

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

Global package reimbursement cap

Policy summaryTotal reimbursement for all physicians may not exceed the amount that would be paid if a single physician provided all services.

Basis for reimbursementReimbursement is based on a percentage of the fee schedule or contracted/negotiated rate for the surgical procedure.

Same procedure code requiredEach physician must use the same surgical procedure code with the appropriate split-care modifier to identify the services provided.

Applies whenWhen more than one physician performs components of the global surgical package (preoperative, procedure, postoperative).

Related adjustmentsAssistant surgeon and multiple procedure rules and fee reductions still apply when applicable.

Authorization and Submission Guidance

Documentation Required

Authorization, medical necessity, and billing/submission requirements

Ensure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence; follow proper billing and submission guidelines using industry‑standard CPT, HCPCS, and/or revenue codes supported by the medical record or office notes. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement.

Verify medical necessity and any prior authorization requirements for the procedure and diagnosis before performing services.
Use correct, industry‑standard CPT, HCPCS, and/or revenue codes on all claim submissions and ensure documentation in the medical record supports billed services.
Be aware that claims may be rejected/denied, paid amounts recovered, or reimbursements adjusted if coding/billing guidelines or policy requirements are not followed.

Policy Definitions

Definitions (general)

Definitions scopeGeneral Reimbursement Policy Definitions covering terms used in reimbursement and billing for surgical services.

Global surgical packageConsists of preoperative services, surgical procedure, and postoperative services; total reimbursement is the same regardless of billing splits.

Split-care modifiersModifiers (e.g., 54, 55, 56) identify which component(s) of the global package each physician performed.

Reimbursement basisPercentages of the fee schedule or contracted/negotiated rate determined by the modifier appended to the procedure code.