Modifiers 54, 55 and 56
This Humana claims payment policy describes reimbursement for services reported with CPT/HCPCS modifiers 54 (surgical care only), 55 (postoperative management only) and 56 (preoperative management only) for Medicare Advantage and Commercial products, and governs how split global surgical package payments are calculated for practitioner services.
No material clinical or coverage changes in this revision.
Split Global Surgical Package — Coverage Rules
Split global surgical package reimbursement criteria
Reimbursement rules for split global surgical package segments:
Preoperative management (Modifier 56)
- Humana allows a charge for preoperative management only, indicated by modifier 56, at the contracted rate or base maximum amount payable under the member's plan multiplied by that service's MPFS preoperative percentage.
Intraoperative care (Modifier 54)
- Humana allows a charge for intraoperative care only, indicated by modifier 54, at the contracted rate or base maximum amount payable under the member's plan multiplied by that service's MPFS intraoperative percentage.
Postoperative management (Modifier 55)
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