CurrentHumanaPolicy CP2O08100

Modifiers 54, 55 and 56

Reimbursement policy describing Humana's payment approach for services reported with CPT modifiers 54, 55, and 56 for global surgical package charges affecting practitioners billing Medicare Advantage and Commercial products.

Policy Summary

PayerHumana

PolicyModifiers 54, 55 and 56

Policy CodePolicy CP2O08100

Change TypeNo material changes

Effective DateMedicare Advantage: 01/2008; Commercial: 03/2008

Next Review Date

Key ActionReport number of postoperative days in the units field consistent with the transfer of postoperative management and follow plan authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3modifiers addressed (54, 55, 56)

01/2008Medicare Advantage effective date

03/2008Commercial effective date

11/2022revision date

Coverage Criteria for Split Global Surgical Services

Humana payment criteria for split global surgical services

Payment rules for split global surgical services billed with modifiers are as follows:

ALL of the following

Preoperative (modifier 56): Humana allows a charge for preoperative management only (modifier 56) at the contracted rate or base maximum amount payable under the member's plan multiplied by the service's MPFS preoperative percentage.

ALL of the following

Intraoperative (modifier 54): Humana allows a charge for intraoperative care only (modifier 54) at the contracted rate or base maximum amount payable under the member's plan multiplied by the service's MPFS intraoperative percentage. A claim submitted with modifier 54 is considered preoperative + intraoperative unless there is a coverable modifier 56 charge for the same procedure code, in which case a modifier 54 claim is considered intraoperative only.

ALL of the following

Policy Summary

PayerHumana

PolicyModifiers 54, 55 and 56

Policy CodePolicy CP2O08100

Change TypeNo material changes

Effective DateMedicare Advantage: 01/2008; Commercial: 03/2008

Next Review Date

Key ActionReport number of postoperative days in the units field consistent with the transfer of postoperative management and follow plan authorization requirements.

SourceLink

On This Page

Coding and Billing: Modifiers and Postoperative Reporting

Global surgery split modifiersModifierCovered

54	Modifier 54: Surgical care only.
55	Modifier 55: Postoperative management only.
56	Modifier 56: Preoperative management only.

Postoperative percentage cap

Postoperative percentage capTotal postoperative management percentages for practitioners may not exceed 100% of the postoperative component for the service; Humana will not allow more than 100% of the postoperative management for that service.

Calculation basisPostoperative payment is the contracted rate or base maximum amount payable under the member's plan multiplied by the service's MPFS postoperative percentage and by the percentage of the global surgery period the practitioner provided care for.

Units reportingPractitioners must report number of postoperative days in the units field consistent with the agreed transfer of postoperative management; MA plans permit out-of-network providers to follow MAC guidance if the MAC directs different reporting.

Provider Responsibilities and Claim Submission Requirements

Billing Rule

Claim reporting of postoperative days

Humana expects the practitioner to report, in the units field on the claim form, the number of postoperative days of service the practitioner provided when billing for postoperative management (modifier 55). Report the actual number of days of postoperative care rendered consistent with any transfer of postoperative management agreement among practitioners. If a Medicare A/B MAC requires a different method for reporting postoperative days, Humana Medicare Advantage plans permit out-of-network providers in that MAC jurisdiction to report days consistent with the MAC guidance.

Report postoperative days in the claim units field when billing modifier 55.
Do not exceed 100% of the postoperative management for the service when combined across practitioners; total postoperative percentages for a global period must equal 100%.
If a MAC (Medicare Administrative Contractor) instructs providers to report postoperative days differently, follow the MAC's reporting guidance for Humana MA plans in that jurisdiction.

Definitions

Global surgical package

DefinitionGlobal surgical package: reimbursement for a procedure includes preoperative, intraoperative and postoperative care and related services; portions may be split among qualified practitioners when there is an agreed transfer of care.

ComponentsIncludes preoperative, intraoperative and postoperative management, complications following surgery, postsurgical pain management and supplies.

ApplicabilityPolicy applies to charges for practitioner services for global surgery procedure codes as identified on the MPFS Relative Value File and does not determine coverage under a specific member plan.

Split global care

DefinitionSplit global care: Global surgical package services provided, under a transfer of care, by multiple qualified healthcare practitioners.

Modifier useQualified practitioners indicate portions of the global surgical package performed by using modifiers 54, 55 and 56, as appropriate.

Reimbursement contextWhen care is transferred, it is appropriate to reimburse the various practitioners for portions of the global surgical package based on MPFS percentages and agreed percentages of postoperative days.

Medicare Physician Fee Schedule (MPFS) Relative Value File

DefinitionMedicare Physician Fee Schedule (MPFS) Relative Value File: a CMS file that includes percentages of the global surgical package for preoperative, intraoperative and postoperative management and the professional procedure RVU.

Use in paymentHumana multiplies the contracted rate or base maximum amount by the service's MPFS preoperative, intraoperative or postoperative percentage to determine allowed amounts for split global services.

Source for procedure listPolicy applies to global surgery procedure codes as identified on the MPFS Relative Value File.

MAC

MAC definitionMAC: Medicare Administrative Contractor.

MAC guidance for reportingIf a Medicare A/B MAC directs providers to report postoperative days differently, Humana MA plans permit out-of-network providers in the jurisdiction to report days consistent with the MAC's guidance.

Relation to Humana plansHumana's MA plans may follow MAC reporting directions for out-of-network providers when applicable; otherwise Humana expects reporting consistent with the agreed transfer of care.